Healthcare Provider Details

I. General information

NPI: 1952421208
Provider Name (Legal Business Name): MOIZ MUSTAFA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-0119
US

IV. Provider business mailing address

PO BOX 100119
GAINESVILLE FL
32610-0119
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8825
  • Fax: 352-273-8800
Mailing address:
  • Phone: 352-273-8825
  • Fax: 352-273-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberME128595
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME128595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: