Provider Demographics
NPI:1659343796
Name:NADAL, FARA (MD)
Entity Type:Individual
Prefix:
First Name:FARA
Middle Name:
Last Name:NADAL
Suffix:
Gender:F
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:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:7001 MERRILL RD STE 10
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-2691
Practice Address - Country:US
Practice Address - Phone:904-744-5244
Practice Address - Fax:904-744-7920
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00112716OtherRR MEDICARE
FL379291900Medicaid
FL23768YMedicare PIN
F73646Medicare UPIN