Healthcare Provider Details

I. General information

NPI: 1053974824
Provider Name (Legal Business Name): MIKAEL FADOUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD STE 1E20
NEWARK DE
19718-2200
US

IV. Provider business mailing address

4755 OGLETOWN STANTON RD STE 1E20
NEWARK DE
19718-2200
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-5700
  • Fax: 302-733-5775
Mailing address:
  • Phone: 302-733-5700
  • Fax: 302-733-5775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberC1-0027330
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: