Basic Information
| Provider Information | |||||||||
| NPI: | 1396372710 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROACHWALA | ||||||||
| FirstName: | MUSTAFA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3249 OAK PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604020715 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 ORLEANS ST | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212870010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109555000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2020 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 125076506 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.