Provider Demographics
NPI:1063155968
Name:ELRAZZAZ, MOSTAFA GAMAL HUSSIEN AB
Entity type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:GAMAL HUSSIEN AB
Last Name:ELRAZZAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 PREMIER KEY DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-5372
Mailing Address - Country:US
Mailing Address - Phone:502-389-8568
Mailing Address - Fax:
Practice Address - Street 1:142 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2922
Practice Address - Country:US
Practice Address - Phone:434-799-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101284055207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program