Provider Demographics
NPI:1558303966
Name:BAROUDI, ISSA F (MD)
Entity Type:Individual
Prefix:DR
First Name:ISSA
Middle Name:F
Last Name:BAROUDI
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 1:3222 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8048
Mailing Address - Country:US
Mailing Address - Phone:941-627-5155
Mailing Address - Fax:
Practice Address - Street 1:3222 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8048
Practice Address - Country:US
Practice Address - Phone:941-627-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38318174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
D58856Medicare UPIN
FL79607AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER