Healthcare Provider Details

I. General information

NPI: 1598386534
Provider Name (Legal Business Name): LUAI SOBHI MUSTAFA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VIRGINIA AVE
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

1100 VIRGINIA AVE
COLUMBIA MO
65212-0001
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-2663
  • Fax:
Mailing address:
  • Phone: 573-882-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: