Healthcare Provider Details

I. General information

NPI: 1255489597
Provider Name (Legal Business Name): M. KHAL ABOUDAN, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

IV. Provider business mailing address

820 PRUDENTIAL DR STE 713
JACKSONVILLE FL
32207-8209
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-5682
  • Fax: 904-346-0864
Mailing address:
  • Phone: 904-396-5682
  • Fax: 904-346-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberME45711
License Number StateFL

VIII. Authorized Official

Name: DR. M. KHAL ABOUDAN
Title or Position: MD
Credential: MD
Phone: 904-396-5682