Healthcare Provider Details

I. General information

NPI: 1194659730
Provider Name (Legal Business Name): MOSTAFA GHULAM HAZRAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENESYS PKWY
GRAND BLANC MI
48439-8065
US

IV. Provider business mailing address

1275 HEATHERWOOD DR APT 7450-3B
GRAND BLANC MI
48439-9293
US

V. Phone/Fax

Practice location:
  • Phone: 810-606-5987
  • Fax:
Mailing address:
  • Phone: 602-321-2693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code211D00000X
TaxonomyPodiatric Assistant
License Number5951001611
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: