1477871705 NPI number — DR. ASIF K MUSTAFA M.D.-PH.D.

Table of content: DR. ASIF K MUSTAFA M.D.-PH.D. (NPI 1477871705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477871705 NPI number — DR. ASIF K MUSTAFA M.D.-PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUSTAFA
Provider First Name:
ASIF
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.-PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477871705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9500 BORMET DR STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOKENA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60448-8399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-346-4044
Provider Business Mailing Address Fax Number:
708-346-3287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 W 95TH ST STE 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK LAWN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60453-2660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-346-4040
Provider Business Practice Location Address Fax Number:
708-346-3287
Provider Enumeration Date:
05/11/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  PENDING , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)