=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366837023
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYED MUSTAFA ALAVI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2015
-----------------------------------------------------
Last Update Date | 08/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1285 HARTREY AVE
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-1056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-666-3494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4234 SW VIEW POINT TER APT B
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-202-0679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD180995
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036150706
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------