Healthcare Provider Details

I. General information

NPI: 1770453052
Provider Name (Legal Business Name): MUSTAFA MUHAMMED ITANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MANCHESTER EXPY STE 1009
COLUMBUS GA
31904-6877
US

IV. Provider business mailing address

2300 MANCHESTER EXPY STE 1009
COLUMBUS GA
31904-6877
US

V. Phone/Fax

Practice location:
  • Phone: 586-413-6501
  • Fax: 833-455-7724
Mailing address:
  • Phone: 586-413-6501
  • Fax: 833-455-7724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number112048
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: