Provider Demographics
NPI:1215188743
Name:JAAFAR, FATAN (MD)
Entity Type:Individual
Prefix:DR
First Name:FATAN
Middle Name:
Last Name:JAAFAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:407-613-2473
Mailing Address - Fax:
Practice Address - Street 1:340 N WYMORE RD STE B
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2823
Practice Address - Country:US
Practice Address - Phone:407-613-2473
Practice Address - Fax:407-613-2474
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110851208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005523100Medicaid
FLPENDINGOtherMEDICARE