Healthcare Provider Details

I. General information

NPI: 1982912002
Provider Name (Legal Business Name): MOSTAFA S SADRY MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 ELECTRIC AVE SUITE 2
PORT HURON MI
48060-6588
US

IV. Provider business mailing address

2603 ELECTRIC AVE SUITE 2
PORT HURON MI
48060-6588
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-4100
  • Fax: 810-985-8244
Mailing address:
  • Phone: 810-985-4100
  • Fax: 810-985-8244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMS044076
License Number StateMI

VIII. Authorized Official

Name: DR. MOSTAFA SEIED SADRY
Title or Position: OWNER
Credential: MD
Phone: 810-985-4100