Provider Demographics
NPI:1386879724
Name:MUSTAFIC, LYDIA (MD)
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:MUSTAFIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 VERSAILLES RD
Mailing Address - Street 2:STE 120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1796
Mailing Address - Country:US
Mailing Address - Phone:859-259-0717
Mailing Address - Fax:859-254-7874
Practice Address - Street 1:2710 SAINT FRANCIS DR STE 210
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5664
Practice Address - Country:US
Practice Address - Phone:319-272-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100179770Medicaid
KY7100179770Medicaid