Provider Demographics
NPI:1730479650
Name:JEROUDI, ABDALLAH MOHAMED (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDALLAH
Middle Name:MOHAMED
Last Name:JEROUDI
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 1:8786 PERIMETER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6347
Mailing Address - Country:US
Mailing Address - Phone:904-997-9202
Mailing Address - Fax:904-997-9205
Practice Address - Street 1:2639 OAK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4505
Practice Address - Country:US
Practice Address - Phone:904-387-5600
Practice Address - Fax:904-388-0114
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA77496207W00000X, 207WX0107X
FLME130764207WX0107X, 207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003188625Medicaid
FL019742700Medicaid