Provider Demographics
NPI:1134143233
Name:AMAWI, BASSAM (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:
Last Name:AMAWI
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 1:450 W STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5187
Mailing Address - Country:US
Mailing Address - Phone:386-299-3393
Mailing Address - Fax:386-257-2119
Practice Address - Street 1:450 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5187
Practice Address - Country:US
Practice Address - Phone:386-299-3393
Practice Address - Fax:386-257-2119
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME506132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2592282Medicaid
FL2592282Medicaid
FL58532Medicare ID - Type Unspecified