Provider Demographics
NPI:1659523983
Name:AWADALLA, ISAM OMER IV
Entity Type:Individual
Prefix:MR
First Name:ISAM
Middle Name:OMER
Last Name:AWADALLA
Suffix:IV
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 1:2100 2ND ST SW
Mailing Address - Street 2:US COAST GUARD HEADQUARTERS MEDICAL
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20593-0002
Mailing Address - Country:US
Mailing Address - Phone:202-372-4100
Mailing Address - Fax:202-372-4912
Practice Address - Street 1:2100 2ND ST SW
Practice Address - Street 2:US COAST GUARD HEADQUARTERS MEDICAL
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20593-0002
Practice Address - Country:US
Practice Address - Phone:202-372-4100
Practice Address - Fax:202-372-4912
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH 18853124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist