Healthcare Provider Details

I. General information

NPI: 1871483669
Provider Name (Legal Business Name): IBRAHIM MUSTAFA KOSAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 10/19/2025
Certification Date: 10/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13930 EDGEWOOD AVE UNIT 123
SAVAGE MN
55378-1302
US

IV. Provider business mailing address

13930 EDGEWOOD AVE UNIT 123
SAVAGE MN
55378-1302
US

V. Phone/Fax

Practice location:
  • Phone: 651-508-0561
  • Fax: 612-979-2646
Mailing address:
  • Phone: 651-508-0561
  • Fax: 612-979-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: