Provider Demographics
NPI:1790112191
Name:DIAB, FADI HASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:FADI
Middle Name:HASAN
Last Name:DIAB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10141 BIG BEND RD STE 206
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-7422
Mailing Address - Country:US
Mailing Address - Phone:813-397-1274
Mailing Address - Fax:813-605-6003
Practice Address - Street 1:10141 BIG BEND RD STE 206
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7422
Practice Address - Country:US
Practice Address - Phone:813-397-1274
Practice Address - Fax:813-605-6003
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253084207RG0100X
IL036091094207RG0100X
FLME117374207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024563000Medicaid
VA1790112191Medicaid