Healthcare Provider Details

I. General information

NPI: 1619468683
Provider Name (Legal Business Name): FANOOS MOHAMMED KHAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 WEKIVA COMMONS CIR
APOPKA FL
32712-3645
US

IV. Provider business mailing address

515 WEKIVA COMMONS CIR
APOPKA FL
32712-3645
US

V. Phone/Fax

Practice location:
  • Phone: 407-464-9516
  • Fax: 407-464-9519
Mailing address:
  • Phone: 407-464-9516
  • Fax: 407-464-9519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number009938
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS17922
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS17922
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: