Provider Demographics
NPI:1659332278
Name:ABOULELA, AYMAN TAHA (MD)
Entity Type:Individual
Prefix:MR
First Name:AYMAN
Middle Name:TAHA
Last Name:ABOULELA
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:P.O. BOX 15834
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32406
Mailing Address - Country:US
Mailing Address - Phone:850-769-1566
Mailing Address - Fax:850-769-1644
Practice Address - Street 1:109 W 23RD N-5
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:850-769-1566
Practice Address - Fax:850-769-1644
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90177208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44090OtherBCBS FLORIDA
FL269881100Medicaid
FLI12074Medicare UPIN
FLI10274Medicare UPIN
FL269881100Medicaid