Healthcare Provider Details

I. General information

NPI: 1568921344
Provider Name (Legal Business Name): MUSTAFA ARCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TER
GLENDALE CA
91206-4007
US

IV. Provider business mailing address

1509 WILSON TER
GLENDALE CA
91206-4007
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-8328
  • Fax:
Mailing address:
  • Phone: 818-409-8328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A20329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: