Healthcare Provider Details

I. General information

NPI: 1801359393
Provider Name (Legal Business Name): NIZAR ABDELFATTAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

IV. Provider business mailing address

130 BLUE CREST LN
DURHAM NC
27705-3685
US

V. Phone/Fax

Practice location:
  • Phone: 626-269-5371
  • Fax: 626-577-2100
Mailing address:
  • Phone: 202-617-8422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number260919
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberPENDING
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number78979
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: