1730594805 NPI number — DR. WISSAM MOHAMED ELFALLAL D.O

Table of content: DR. WISSAM MOHAMED ELFALLAL D.O (NPI 1730594805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730594805 NPI number — DR. WISSAM MOHAMED ELFALLAL D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELFALLAL
Provider First Name:
WISSAM
Provider Middle Name:
MOHAMED
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
M

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:
1730594805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 863381
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32886-3381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-231-3249
Provider Business Mailing Address Fax Number:
386-672-9904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 MEMORIAL MEDICAL PKWY STE 505
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32117-5170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-231-3540
Provider Business Practice Location Address Fax Number:
386-231-3544
Provider Enumeration Date:
06/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  OS17401 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207T00000X , with the licence number: 5101021284 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 110255800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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