Provider Demographics
NPI:1710060793
Name:BAHTA, IRENE FADULLON (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:FADULLON
Last Name:BAHTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 260101
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-7101
Mailing Address - Country:US
Mailing Address - Phone:954-392-5696
Mailing Address - Fax:954-392-5668
Practice Address - Street 1:10794 PINES BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3920
Practice Address - Country:US
Practice Address - Phone:954-392-5696
Practice Address - Fax:954-392-5668
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME71906207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32755YMedicare PIN
FLGF84257Medicare UPIN