Provider Demographics
NPI:1568451557
Name:CHALHOUB, FADI
Entity Type:Individual
Prefix:
First Name:FADI
Middle Name:
Last Name:CHALHOUB
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 550763
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-0763
Mailing Address - Country:US
Mailing Address - Phone:904-307-7404
Mailing Address - Fax:
Practice Address - Street 1:4131 UNIVERSITY BLVD S
Practice Address - Street 2:BLDG #6
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4326
Practice Address - Country:US
Practice Address - Phone:904-737-4126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH52372Medicare UPIN
FL03092Medicare ID - Type Unspecified