Provider Demographics
NPI:1992088082
Name:MUSTAFA, DIANE M (MD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:M
Last Name:MUSTAFA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:BAMGBADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:916 MAIN AVE STE 2C
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-8545
Mailing Address - Country:US
Mailing Address - Phone:973-200-2794
Mailing Address - Fax:973-777-9405
Practice Address - Street 1:916 MAIN AVE STE 2C
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-8545
Practice Address - Country:US
Practice Address - Phone:973-200-2794
Practice Address - Fax:973-777-9405
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-24
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA09377500207VG0400X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology