Provider Demographics
NPI:1083292452
Name:ABOU GHAIDA, FADEL
Entity Type:Individual
Prefix:
First Name:FADEL
Middle Name:
Last Name:ABOU GHAIDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11375 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5409
Mailing Address - Country:US
Mailing Address - Phone:352-596-6632
Mailing Address - Fax:
Practice Address - Street 1:1055 CRYSTAL BAY LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-6636
Practice Address - Country:US
Practice Address - Phone:407-690-9512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME167079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine