Healthcare Provider Details

I. General information

NPI: 1205280542
Provider Name (Legal Business Name): SHAHRUKH MUSTAFA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 MAIN ST
NEW PALTZ NY
12561-1623
US

IV. Provider business mailing address

396 BROADWAY
KINGSTON NY
12401-4626
US

V. Phone/Fax

Practice location:
  • Phone: 845-255-2930
  • Fax: 845-255-3089
Mailing address:
  • Phone: 845-802-7600
  • Fax: 845-338-0307

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 State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number301251
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: