Provider Demographics
NPI:1609883180
Name:MUSTAFA, SYED JAMAL (MD)
Entity type:Individual
Prefix:
First Name:SYED
Middle Name:JAMAL
Last Name:MUSTAFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4247
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98009-4247
Mailing Address - Country:US
Mailing Address - Phone:425-488-7367
Mailing Address - Fax:425-488-8516
Practice Address - Street 1:10634 E RIVERSIDE DR STE 130
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3758
Practice Address - Country:US
Practice Address - Phone:425-806-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000342192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1112333Medicaid
WA1112333Medicaid
WAG8866787Medicare PIN