Provider Demographics
NPI:1427400175
Name:EDRISKHALAF, FATEN (OD)
Entity Type:Individual
Prefix:
First Name:FATEN
Middle Name:
Last Name:EDRISKHALAF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BISCAYNE BLVD
Mailing Address - Street 2:3602
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33132-2905
Mailing Address - Country:US
Mailing Address - Phone:786-452-6690
Mailing Address - Fax:
Practice Address - Street 1:4302 ALTON RD STE 300
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140
Practice Address - Country:US
Practice Address - Phone:305-672-9989
Practice Address - Fax:786-245-2006
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5216152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIU041UOtherMEDICARE