Provider Demographics
NPI:1083878300
Name:AL BALBISSI, LAITH ADLI (MD)
Entity Type:Individual
Prefix:
First Name:LAITH
Middle Name:ADLI
Last Name:AL BALBISSI
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 1:7236 STONEROCK CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8000
Mailing Address - Country:US
Mailing Address - Phone:321-841-6444
Mailing Address - Fax:407-370-5820
Practice Address - Street 1:7236 STONEROCK CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8000
Practice Address - Country:US
Practice Address - Phone:321-841-6444
Practice Address - Fax:407-370-5820
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1452832086S0129X
TXQ5612208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63075211Medicaid
TX352164302Medicaid
FL106291400Medicaid
TX352164301Medicaid
OK200606530 AMedicaid