Basic Information
| Provider Information | |||||||||
| NPI: | 1588194633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUSTAFA | ||||||||
| FirstName: | ADEEB | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MUSTAFA | ||||||||
| OtherFirstName: | ADEEB | ||||||||
| OtherMiddleName: | N | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11375 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346135409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525792753 | ||||||||
| FaxNumber: | 3525916317 | ||||||||
| Practice Location | |||||||||
| Address1: | 11375 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346135409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525792753 | ||||||||
| FaxNumber: | 3525916317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2017 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | ME144774 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | ME144774 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.