1912764788 NPI number — OSAMA SHUAIB ISMAIL MD LLC

Table of content: (NPI 1225237514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912764788 NPI number — OSAMA SHUAIB ISMAIL MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OSAMA SHUAIB ISMAIL MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912764788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 E BYRD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONIFAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32425-3004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 E BYRD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONIFAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32425-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-547-2305
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2024

Additional Information

Authorized Official

Authorized Official Last Name:
ISMAIL
Authorized Official First Name:
OSAMA
Authorized Official Middle Name:
SHUAIB
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-319-3361

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 122654600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com