Provider Demographics
NPI:1134124753
Name:FABIAN, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:FABIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:1890 LPGA BLVD
Practice Address - Street 2:STE 250
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7131
Practice Address - Country:US
Practice Address - Phone:386-274-0250
Practice Address - Fax:386-274-0269
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2013-01-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME00535772086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004286OtherFHCP
FL004286OtherFHCP
FLF56633Medicare UPIN