Provider Demographics
NPI:1710596861
Name:ALTANTAWI, ABDALLAH MAHMOUD (MD)
Entity Type:Individual
Prefix:
First Name:ABDALLAH
Middle Name:MAHMOUD
Last Name:ALTANTAWI
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 1:4870 DEER LAKE DR E FL 32246
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6300
Mailing Address - Country:US
Mailing Address - Phone:904-633-4199
Mailing Address - Fax:
Practice Address - Street 1:841 PRUDENTIAL DR STE 1130
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8331
Practice Address - Country:US
Practice Address - Phone:904-633-4199
Practice Address - Fax:904-633-4188
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31948208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics