Healthcare Provider Details

I. General information

NPI: 1164064531
Provider Name (Legal Business Name): SEID YUSUF MULIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BEAUVOIR AVE # 3533
SUMMIT NJ
07901-3533
US

IV. Provider business mailing address

60 BERGEN AVE
TEANECK NJ
07666-3803
US

V. Phone/Fax

Practice location:
  • Phone: 908-522-2232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024062
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: