Basic Information
| Provider Information | |||||||||
| NPI: | 1609437219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUSTAFA | ||||||||
| FirstName: | JALLA | ||||||||
| MiddleName: | TARAK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4106 EMERICK CT | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165066410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582133620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5515 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165092695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148688217 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2019 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OT019576 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 009516 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.