Healthcare Provider Details

I. General information

NPI: 1386879724
Provider Name (Legal Business Name): LYDIA MUSTAFIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 SAINT FRANCIS DR STE 210
WATERLOO IA
50702-5664
US

IV. Provider business mailing address

1306 VERSAILLES RD STE 120
LEXINGTON KY
40504-1796
US

V. Phone/Fax

Practice location:
  • Phone: 319-272-5000
  • Fax:
Mailing address:
  • Phone: 859-259-0717
  • Fax: 859-254-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number44461
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: