Provider Demographics
NPI:1679072045
Name:MOUSTAFA, MAHMOUD
Entity type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:MOUSTAFA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5584
Mailing Address - Street 2:ALINE
Mailing Address - City:BROSSARD
Mailing Address - State:QC
Mailing Address - Zip Code:418
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7785 N STATE ST
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1229
Practice Address - Country:US
Practice Address - Phone:315-376-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292552207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology