Provider Demographics
NPI:1932283389
Name:FAWAZ, FAWZI (M D)
Entity Type:Individual
Prefix:DR
First Name:FAWZI
Middle Name:
Last Name:FAWAZ
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:962 US HIGHWAY 331 S
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-3372
Mailing Address - Country:US
Mailing Address - Phone:850-951-8800
Mailing Address - Fax:850-951-0203
Practice Address - Street 1:962 US HIGHWAY 331 S
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-3372
Practice Address - Country:US
Practice Address - Phone:850-951-8800
Practice Address - Fax:850-951-0203
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82523207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE64361Medicare UPIN