Healthcare Provider Details

I. General information

NPI: 1851635122
Provider Name (Legal Business Name): MUSTAFA MUHAMMAD IDRIS DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 159TH AVE NE BUILDING 21
REDMOND WA
98052-6309
US

IV. Provider business mailing address

18525 NE 58TH CT APT N2105
REDMOND WA
98052-6708
US

V. Phone/Fax

Practice location:
  • Phone: 425-216-0550
  • Fax: 425-216-0552
Mailing address:
  • Phone: 425-638-3092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberCH60261762
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: