=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376067355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. MOSTAFA MEDHATI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 265 LEXINGTON ST.
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-928-7678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 265 LEXINGTON ST.
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-928-7678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------