Healthcare Provider Details

I. General information

NPI: 1558370411
Provider Name (Legal Business Name): QAHTAN A ABDULFATTAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11323 CORTEZ BLVD
BROOKSVILLE FL
34613-5407
US

IV. Provider business mailing address

14690 SPRING HILL DR SUITE 100 ATTN:CREDENTIALING
SPRING HILL FL
34609-8102
US

V. Phone/Fax

Practice location:
  • Phone: 352-596-8344
  • Fax: 352-597-2898
Mailing address:
  • Phone: 352-799-0046
  • Fax: 352-606-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberME92671
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: