MEDICARE: DR. MUSTAPHA AHMAD EZZEDDINE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	49900	MN
2	2084V0102X	Vascular Neurology Physician	49900	MN
3	2084N0400X	Neurology Physician	2019-02683	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972534667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MUSTAPHA AHMAD EZZEDDINE M.D.

Provider Business Mailing Address
First Line	:	420 DELAWARE ST SE
Second Line	:	MMC 295
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55455-0341
Country	:	US
Telephone Number	:	612-625-9900
Fax Number	:	612-625-7950

Provider Business Practice Location Address
First Line	:	MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-0356
Country	:	US
Telephone Number	:	336-716-2255
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	11/11/2019

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