Healthcare Provider Details

I. General information

NPI: 1932595907
Provider Name (Legal Business Name): MOUSTAFA K MOUSTAFA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST BOX 800719
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

12912 KAIN RD
GLEN ALLEN VA
23059-5733
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-2150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101262699
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: