Provider Demographics
NPI:1811087844
Name:MOUSTAFA, TAREK SHAABAN (MD)
Entity type:Individual
Prefix:DR
First Name:TAREK
Middle Name:SHAABAN
Last Name:MOUSTAFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3455 MILL RUN DRIVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-9083
Mailing Address - Country:US
Mailing Address - Phone:614-771-2222
Mailing Address - Fax:614-771-2221
Practice Address - Street 1:2658 W. LASKEY ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-3288
Practice Address - Country:US
Practice Address - Phone:419-473-8105
Practice Address - Fax:419-254-2121
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-03-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010838972085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2590941Medicaid
MI4766161Medicaid
4243301Medicare PIN
MI0H17609472Medicare ID - Type Unspecified
OH2590941Medicaid
MII39469Medicare UPIN