Basic Information
| Provider Information | |||||||||
| NPI: | 1043266174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUSHTAQ | ||||||||
| FirstName: | MIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 315 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026292500 | ||||||||
| FaxNumber: | 5026292055 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 GORDON GUTMANN BLVD | ||||||||
| Address2: | STE 301 | ||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471303764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122889969 | ||||||||
| FaxNumber: | 8122889657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 01047786A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 200437800 | 05 | IN | MEDICAID | 64053093 | 05 | KY | MEDICAID |