Provider Demographics
NPI:1518059906
Name:HIMADA, FAWZI M (MD)
Entity Type:Individual
Prefix:DR
First Name:FAWZI
Middle Name:M
Last Name:HIMADA
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 1:811 NORTH 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015
Mailing Address - Country:US
Mailing Address - Phone:229-273-5575
Mailing Address - Fax:229-273-5075
Practice Address - Street 1:811 N. 4TH ST.
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-273-5575
Practice Address - Fax:229-273-5075
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047442208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000837691DMedicaid