Provider Demographics
NPI:1366970576
Name:AZIMUDDIN, MUSTAFA SYED (DO)
Entity type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:SYED
Last Name:AZIMUDDIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4328 OLD GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403-9489
Mailing Address - Country:US
Mailing Address - Phone:262-687-7606
Mailing Address - Fax:
Practice Address - Street 1:4328 OLD GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53403-9489
Practice Address - Country:US
Practice Address - Phone:262-687-7606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125070421390200000X
WI73923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program