Healthcare Provider Details

I. General information

NPI: 1831115559
Provider Name (Legal Business Name): MOHAMADO MUSTHAQ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N COLUMBUS BLVD
PHILADELPHIA PA
19123-4226
US

IV. Provider business mailing address

505 MONTICELLO LN
PLYMOUTH MEETING PA
19462-1275
US

V. Phone/Fax

Practice location:
  • Phone: 215-923-8042
  • Fax: 215-923-8064
Mailing address:
  • Phone: 484-213-4712
  • Fax: 215-923-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD062265L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: