Basic Information
| Provider Information | |||||||||
| NPI: | 1619023223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUSTAFA | ||||||||
| FirstName: | SYED | ||||||||
| MiddleName: | SHAHZAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 W RIDGE RD STE 5 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146262801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859228350 | ||||||||
| FaxNumber: | 5859228355 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 W RIDGE RD | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146262801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859228350 | ||||||||
| FaxNumber: | 5859223315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 252196 | NY | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 03118994 | 05 | NY | MEDICAID |