Provider Demographics
NPI:1912967860
Name:ASHOURI, FAWAZ M (MD)
Entity Type:Individual
Prefix:DR
First Name:FAWAZ
Middle Name:M
Last Name:ASHOURI
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 1:2301 UNIVERSITY BLVD W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2022
Mailing Address - Country:US
Mailing Address - Phone:904-396-3700
Mailing Address - Fax:904-398-3871
Practice Address - Street 1:2301 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217
Practice Address - Country:US
Practice Address - Phone:904-396-3700
Practice Address - Fax:904-398-3871
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38972208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069570000Medicaid
FL15732Medicare ID - Type Unspecified