Provider Demographics
NPI:1770614786
Name:THE HEADACHE AND NEUROLOGY CLINIC PA
Entity type:Organization
Organization Name:THE HEADACHE AND NEUROLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:QAHTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDULFATTAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-596-8344
Mailing Address - Street 1:11373 CORTEZ BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5411
Mailing Address - Country:US
Mailing Address - Phone:352-596-8344
Mailing Address - Fax:352-597-2898
Practice Address - Street 1:11373 CORTEZ BLVD STE 303
Practice Address - Street 2:303
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5411
Practice Address - Country:US
Practice Address - Phone:352-596-8344
Practice Address - Fax:352-597-2898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92671204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1558370411OtherPROVIDER'S INDIVIDUAL NPI