Healthcare Provider Details

I. General information

NPI: 1144422544
Provider Name (Legal Business Name): SYED MUSTAFA SHAHKHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 MINNESOTA DR STE 200
BLOOMINGTON MN
55435-5281
US

IV. Provider business mailing address

2828 CHICAGO AVENUE SUITE 200
MINNEAPOLIS MN
55407
US

V. Phone/Fax

Practice location:
  • Phone: 612-879-1000
  • Fax: 612-879-9116
Mailing address:
  • Phone: 612-879-1000
  • Fax: 612-879-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number50338
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number50338
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number50338
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: