Basic Information
| Provider Information | |||||||||
| NPI: | 1174725329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSTOFA | ||||||||
| FirstName: | GOLAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7172174218 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172174300 | ||||||||
| FaxNumber: | 7172174217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD432142 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD432142 | PA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 102023150 0002 | 05 | PA | MEDICAID |