Healthcare Provider Details

I. General information

NPI: 1245641307
Provider Name (Legal Business Name): MUSTAFA S MAWIH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 THOMAS MORE PKWY STE 200
EDGEWOOD KY
41017-5103
US

IV. Provider business mailing address

5333 MCAULEY DR RM 4003
YPSILANTI MI
48197-1099
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-6281
  • Fax: 859-341-4661
Mailing address:
  • Phone: 734-712-3470
  • Fax: 734-712-2935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301503360
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: