Basic Information
| Provider Information | |||||||||
| NPI: | 1386879724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUSTAFIC | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 VERSAILLES RD | ||||||||
| Address2: | STE 120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592590717 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 SAINT FRANCIS DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192725000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44461 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100179770 | 05 | KY | MEDICAID |