Healthcare Provider Details

I. General information

NPI: 1700414612
Provider Name (Legal Business Name): HAZIM MOUSTAFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 COMMACK RD
COMMACK NY
11725-5020
US

IV. Provider business mailing address

1500 ROUTE 112
PORT JEFFERSON STATION NY
11776-8054
US

V. Phone/Fax

Practice location:
  • Phone: 631-828-7220
  • Fax: 631-828-7899
Mailing address:
  • Phone: 631-828-7220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number331573
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: