Basic Information
Provider Information | |||||||||
NPI: | 1396976080 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOSTAFA | ||||||||
FirstName: | ASHRAF | ||||||||
MiddleName: | EHAB | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15150 FORT ST | ||||||||
Address2: |   | ||||||||
City: | SOUTHGATE | ||||||||
State: | MI | ||||||||
PostalCode: | 48195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342824800 | ||||||||
FaxNumber: | 7342829302 | ||||||||
Practice Location | |||||||||
Address1: | 1257 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LAPEER | ||||||||
State: | MI | ||||||||
PostalCode: | 484461346 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8109694040 | ||||||||
FaxNumber: | 8107887894 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2009 | ||||||||
LastUpdateDate: | 11/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 4301094562 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207RI0011X | 4301094562 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.