Provider Demographics
NPI:1932593746
Name:MUSTAFA, GHULAM (MD)
Entity Type:Individual
Prefix:
First Name:GHULAM
Middle Name:
Last Name:MUSTAFA
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 1:185 RYKOWSKI LN STE 101
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4055
Mailing Address - Country:US
Mailing Address - Phone:845-692-0030
Mailing Address - Fax:845-692-0037
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:717-531-8044
Practice Address - Fax:717-531-5596
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300217207U00000X
NY300217-01207UN0902X
PAMD4679242085R0202X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06368125Medicaid