Provider Demographics
NPI:1740455856
Name:FARAGALLAH, MOUSTAFA AHMED (PT)
Entity type:Individual
Prefix:
First Name:MOUSTAFA
Middle Name:AHMED
Last Name:FARAGALLAH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 60TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-2434
Mailing Address - Country:US
Mailing Address - Phone:718-331-6323
Mailing Address - Fax:
Practice Address - Street 1:2055 60TH ST APT 4
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-2434
Practice Address - Country:US
Practice Address - Phone:718-331-6323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014922208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014922Other014922