Provider Demographics
NPI:1811982762
Name:SIDALI, MUSTAFA M (DO)
Entity type:Individual
Prefix:DR
First Name:MUSTAFA
Middle Name:M
Last Name:SIDALI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55-59 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109
Mailing Address - Country:US
Mailing Address - Phone:973-207-0640
Mailing Address - Fax:
Practice Address - Street 1:55-59 WASHINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109
Practice Address - Country:US
Practice Address - Phone:973-207-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06569500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7449500Medicaid
NJ002077PDOMedicare UPIN
NJG59826Medicare UPIN
NJ7449500Medicaid