Provider Demographics
NPI:1902870470
Name:MUSTAFA, TARIF HUSSEIN SR (MD)
Entity Type:Individual
Prefix:DR
First Name:TARIF
Middle Name:HUSSEIN
Last Name:MUSTAFA
Suffix:SR
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 1:12940 W WARREN
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126
Mailing Address - Country:US
Mailing Address - Phone:313-945-8210
Mailing Address - Fax:313-945-0729
Practice Address - Street 1:12940 W WARREN
Practice Address - Street 2:WARREN MEDICAL CENTER
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-945-8210
Practice Address - Fax:313-945-0729
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2751061Medicaid
MI2751061Medicaid
E92607Medicare UPIN