Basic Information
Provider Information | |||||||||
NPI: | 1295266534 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MUSTROPH | ||||||||
FirstName: | MARTINA | ||||||||
MiddleName: | LAETITIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 209 N COLER AVE | ||||||||
Address2: | APT 5 | ||||||||
City: | URBANA | ||||||||
State: | IL | ||||||||
PostalCode: | 618018102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4049932808 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 75 FRANCIS STREET | ||||||||
Address2: | BWH DEPT. OF NEUROSURGERY | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177326600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2017 | ||||||||
LastUpdateDate: | 03/27/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.