Provider Demographics
NPI:1932194511
Name:HADDAD, FADI (MD)
Entity Type:Individual
Prefix:
First Name:FADI
Middle Name:
Last Name:HADDAD
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 1:822 W 1ST ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2384
Mailing Address - Country:US
Mailing Address - Phone:812-331-8168
Mailing Address - Fax:812-331-1096
Practice Address - Street 1:822 W 1ST ST
Practice Address - Street 2:SUITE 8
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2384
Practice Address - Country:US
Practice Address - Phone:812-331-8168
Practice Address - Fax:812-331-1096
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051484A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H12657Medicare UPIN
IN188420Medicare PIN