Healthcare Provider Details

I. General information

NPI: 1831802792
Provider Name (Legal Business Name): TAREK AJAMI FARDOUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3290 DAUPHIN ST STE 301
MOBILE AL
36606-4052
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 251-660-5930
  • Fax: 251-660-5931
Mailing address:
  • Phone: 866-401-3057
  • Fax: 318-868-6430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMFC1876
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: