Provider Demographics
NPI:1245752021
Name:MOURSI, FOUAD SAM (MD)
Entity Type:Individual
Prefix:MR
First Name:FOUAD
Middle Name:SAM
Last Name:MOURSI
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 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1514 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-2476
Practice Address - Country:US
Practice Address - Phone:866-234-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22415207P00000X, 207Q00000X
FLACN1397208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine