Healthcare Provider Details

I. General information

NPI: 1891226486
Provider Name (Legal Business Name): ALI M MUSTAFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RENAISSANCE SQUARE, 141 ROUTE 70, SUITE B
MARLTON NJ
08053
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-596-9057
  • Fax: 856-596-0837
Mailing address:
  • Phone: 856-596-9057
  • Fax: 856-596-0837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25MA12129000
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number305207
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: