Provider Demographics
NPI:1740275551
Name:FAZAL, MUBASHER (MD)
Entity type:Individual
Prefix:DR
First Name:MUBASHER
Middle Name:
Last Name:FAZAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W 12TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4500
Mailing Address - Country:US
Mailing Address - Phone:814-877-8730
Mailing Address - Fax:814-877-8731
Practice Address - Street 1:2500 W 12TH ST STE C
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4500
Practice Address - Country:US
Practice Address - Phone:814-877-8730
Practice Address - Fax:814-877-8731
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067859L207QS1201X
VA0101243795207QS1201X, 208M00000X
MDD0068524207Q00000X, 207QS1201X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740275551Medicaid
VA196357OtherMEDICARE DC/FAIRFAX
VAA175OtherMEDICARE VA OTHER
H00226Medicare UPIN