Provider Demographics
NPI:1831115559
Name:MUSTHAQ, MOHAMADO (MD)
Entity type:Individual
Prefix:
First Name:MOHAMADO
Middle Name:
Last Name:MUSTHAQ
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 1:505 MONTICELLO LN
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1275
Mailing Address - Country:US
Mailing Address - Phone:484-213-4712
Mailing Address - Fax:215-923-8064
Practice Address - Street 1:520 N COLUMBUS BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-4226
Practice Address - Country:US
Practice Address - Phone:215-923-8042
Practice Address - Fax:215-923-8064
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062265L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA568611-000OtherMIS
PA568611-000OtherMIS
PACB6719Medicare UPIN