Healthcare Provider Details

I. General information

NPI: 1215851787
Provider Name (Legal Business Name): MUSTAFAA ISLAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 S. CENTER ST
SPRINGFIELD OH
45506
US

IV. Provider business mailing address

137 W JOHN ST
SPRINGFIELD OH
45506-3431
US

V. Phone/Fax

Practice location:
  • Phone: 937-815-7488
  • Fax:
Mailing address:
  • Phone: 937-360-7684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: