Provider Demographics
NPI:1982626537
Name:HADDAD, FADI GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:FADI
Middle Name:GEORGE
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 1:8275 ROYALL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9340
Mailing Address - Country:US
Mailing Address - Phone:510-813-4747
Mailing Address - Fax:877-992-2989
Practice Address - Street 1:5201 DEER VALLEY RD STE 1E
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-7430
Practice Address - Country:US
Practice Address - Phone:925-350-8855
Practice Address - Fax:925-350-8860
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK44482080P0206X
CAC515752080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C515750Medicaid
CAC51575OtherMEDICAL LICENSE
450-107-8OtherECFMG
450-107-8OtherECFMG
BH4323515OtherDEA
00C515750Medicare ID - Type Unspecified