Provider Demographics
NPI:1477674232
Name:AYYOUB, SHADI
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:AYYOUB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-819-4082
Mailing Address - Fax:904-819-5156
Practice Address - Street 1:400 HEALTH PARK BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5784
Practice Address - Country:US
Practice Address - Phone:904-819-4082
Practice Address - Fax:904-819-5156
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44249207R00000X
AZ37193207R00000X
FLME119332208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ277141Medicaid
AZ277141Medicaid