Healthcare Provider Details

I. General information

NPI: 1952891509
Provider Name (Legal Business Name): MUSTAFA KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 W MAIN ST # 101
STAMFORD CT
06902-4536
US

IV. Provider business mailing address

2015 W MAIN ST STE 101
STAMFORD CT
06902-4536
US

V. Phone/Fax

Practice location:
  • Phone: 203-863-3750
  • Fax:
Mailing address:
  • Phone: 203-863-3750
  • Fax: 203-863-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number73543
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: