Provider Demographics
NPI:1023007135
Name:ALBANNA, ISSAM I (MD)
Entity Type:Individual
Prefix:DR
First Name:ISSAM
Middle Name:I
Last Name:ALBANNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3288 COVE BEND DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2752
Mailing Address - Country:US
Mailing Address - Phone:813-979-4435
Mailing Address - Fax:813-979-4026
Practice Address - Street 1:3288 COVE BEND DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2752
Practice Address - Country:US
Practice Address - Phone:813-979-4435
Practice Address - Fax:813-979-4026
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061731208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379455500Medicaid
FLE0931Medicare ID - Type Unspecified
G73747Medicare UPIN