Provider Demographics
NPI:1255489597
Name:M. KHAL ABOUDAN, MD
Entity Type:Organization
Organization Name:M. KHAL ABOUDAN, MD
Other - Org Name:M. KHAL ABOUDAN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:M. KHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOUDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-396-5682
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45711207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00687475AMedicaid
FL02583OtherBCBS OF FL
FL02583OtherBCBS OF FL
GA00687475AMedicaid