Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | G-25049 | CA |
NPI | 1033661962 |
---|---|
Provider Name | Dr. Michael Mustille |
First Address | Oakland, CA 94611-1841 |
Second Address | Oakland, CA 94611-1841 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2016 |
Last Update Date | 26/10/2016 |