Provider Demographics
NPI:1619144045
Name:ISSA, HANI (MD)
Entity Type:Individual
Prefix:DR
First Name:HANI
Middle Name:
Last Name:ISSA
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 1:1907 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3405
Mailing Address - Country:US
Mailing Address - Phone:043-883-3519
Mailing Address - Fax:904-389-3507
Practice Address - Street 1:2 PAVILLON PLACE
Practice Address - Street 2:
Practice Address - City:PENNY FARMS
Practice Address - State:FL
Practice Address - Zip Code:32079
Practice Address - Country:US
Practice Address - Phone:904-388-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050623207R00000X
FLME133628207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME133628OtherMEDICAL LICENSE