Provider Demographics
NPI:1689692956
Name:HADDAD, FADI
Entity Type:Individual
Prefix:DR
First Name:FADI
Middle Name:
Last Name:HADDAD
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 1:8860 CENTER DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3068
Mailing Address - Country:US
Mailing Address - Phone:619-376-1904
Mailing Address - Fax:619-376-1909
Practice Address - Street 1:8860 CENTER DR
Practice Address - Street 2:SUITE 320
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3068
Practice Address - Country:US
Practice Address - Phone:619-376-1904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80687207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64068463Medicaid
KY0775201Medicare ID - Type Unspecified
KY64068463Medicaid