1255489597 NPI number — M. KHAL ABOUDAN, MD

Table of content: (NPI 1255489597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255489597 NPI number — M. KHAL ABOUDAN, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M. KHAL ABOUDAN, MD
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:
M. KHAL ABOUDAN MD
Provider Other Organization Name Type Code:
3
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:
1255489597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 PRUDENTIAL DR STE 713
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32207-8209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-396-5682
Provider Business Mailing Address Fax Number:
904-346-0864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 PRUDENTIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-8202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-396-5682
Provider Business Practice Location Address Fax Number:
904-346-0864
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ABOUDAN
Authorized Official First Name:
M. KHAL
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
904-396-5682

Provider Taxonomy Codes

  • Taxonomy code: 207PP0204X , with the licence number:  ME45711 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00687475A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02583 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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