Healthcare Provider Details

I. General information

NPI: 1609883180
Provider Name (Legal Business Name): SYED JAMAL MUSTAFA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10634 E RIVERSIDE DR STE 130
BOTHELL WA
98011-3758
US

IV. Provider business mailing address

PO BOX 4247
BELLEVUE WA
98009-4247
US

V. Phone/Fax

Practice location:
  • Phone: 425-806-5021
  • Fax:
Mailing address:
  • Phone: 425-488-7367
  • Fax: 425-488-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD00034219
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1112333
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: