Healthcare Provider Details

I. General information

NPI: 1457489288
Provider Name (Legal Business Name): MUSTAFA BARBOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E GRAY ST SUITE 601
LOUISVILLE KY
40202-3902
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-3600
  • Fax: 502-588-9536
Mailing address:
  • Phone: 502-588-3600
  • Fax: 502-588-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number7980
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number41948
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41948
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7980
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: