Provider Demographics
NPI:1700947082
Name:MUSTY, MICHAEL OWEN SR (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:OWEN
Last Name:MUSTY
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:OWEN
Other - Last Name:MUSTY
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10710 PINE BEACH PENINSULA LOOP
Mailing Address - Street 2:
Mailing Address - City:EAST GULL LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2027
Mailing Address - Country:US
Mailing Address - Phone:218-330-1139
Mailing Address - Fax:
Practice Address - Street 1:10710 PINE BEACH PENINSULA LOOP
Practice Address - Street 2:
Practice Address - City:EAST GULL LAKE
Practice Address - State:MN
Practice Address - Zip Code:56401-2027
Practice Address - Country:US
Practice Address - Phone:218-330-1139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine