=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063961894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUSTAFA HARES, M.D. P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2016
-----------------------------------------------------
Last Update Date | 09/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22401 FOSTER WINTER DR
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-3724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-371-3199
-----------------------------------------------------
Fax | 248-371-1930
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22401 FOSTER WINTER DR
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-3724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-371-3199
-----------------------------------------------------
Fax | 248-371-1930
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MUSTAFA HARES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 248-371-3199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 4301040359
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------