Provider Demographics
NPI:1285785352
Name:MOSTAFA, MAHMOUD I (MD)
Entity type:Individual
Prefix:DR
First Name:MAHMOUD
Middle Name:I
Last Name:MOSTAFA
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 1:1301 TAYLOR ST STE 3L
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2948
Mailing Address - Country:US
Mailing Address - Phone:803-252-0470
Mailing Address - Fax:803-252-0611
Practice Address - Street 1:1301 TAYLOR ST STE 3L
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2948
Practice Address - Country:US
Practice Address - Phone:803-252-0470
Practice Address - Fax:803-252-0611
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8219Medicaid
SC8219Medicaid