Provider Demographics
NPI:1922685544
Name:FADOUL, PETER SAMI (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:SAMI
Last Name:FADOUL
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 1:336 HILLRIDGE CV
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-3633
Mailing Address - Country:US
Mailing Address - Phone:478-318-8866
Mailing Address - Fax:
Practice Address - Street 1:380 HOSPITAL DR STE 430
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-8017
Practice Address - Country:US
Practice Address - Phone:478-318-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program