Basic Information
| Provider Information | |||||||||
| NPI: | 1558829333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MUSTAFIZUR CHOUDHURY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3148 ESCH DR | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480911651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862918255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6071 W OUTER DR | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482352624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139663300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2019 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | CHOUDHURY | ||||||||
| AuthorizedOfficialFirstName: | MUSTAFIZUR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5862918255 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.