Provider Demographics
NPI:1881078533
Name:MUSTAFA, KHADER
Entity type:Individual
Prefix:
First Name:KHADER
Middle Name:
Last Name:MUSTAFA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 MONROE ST UNIT 202
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2735
Mailing Address - Country:US
Mailing Address - Phone:567-585-0115
Mailing Address - Fax:
Practice Address - Street 1:5700 MONROE ST UNIT 202
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560
Practice Address - Country:US
Practice Address - Phone:567-585-0115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063837207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0892673Medicaid