Provider Demographics
NPI:1003351867
Name:FAWAZ M ASHOURI
Entity Type:Organization
Organization Name:FAWAZ M ASHOURI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-396-3700
Mailing Address - Street 1:2301 UNIVERSITY BLVD W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2022
Mailing Address - Country:US
Mailing Address - Phone:904-396-3700
Mailing Address - Fax:
Practice Address - Street 1:2301 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2022
Practice Address - Country:US
Practice Address - Phone:904-396-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38972174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15732WMedicare PIN
FL15732YMedicare PIN