Provider Demographics
NPI:1144419466
Name:ABOUDAN, MOHAMMAD KHALDOUN (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:KHALDOUN
Last Name:ABOUDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KHAL
Other - Middle Name:
Other - Last Name:ABOUDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:820 PRUDENTIAL DR STE 713
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8209
Mailing Address - Country:US
Mailing Address - Phone:904-396-5682
Mailing Address - Fax:904-346-0864
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:904-346-0864
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45711208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0447145-00Medicaid
GA00687475AMedicaid
FL02583OtherBCBS OF FLORIDA
FL02583OtherBCBS OF FLORIDA
FLE12128Medicare UPIN