Healthcare Provider Details

I. General information

NPI: 1629398441
Provider Name (Legal Business Name): LAILAH ISSAC DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 COLLEGE AVE RM 1433
DAVIE FL
33314-7722
US

IV. Provider business mailing address

PO BOX 290370
DAVIE FL
33329-0370
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-5590
  • Fax: 954-262-5570
Mailing address:
  • Phone: 954-262-4317
  • Fax: 954-262-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS14744
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: