Healthcare Provider Details

I. General information

NPI: 1578067955
Provider Name (Legal Business Name): ISSA HANNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 09/29/2026
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR STE 1130
JACKSONVILLE FL
32207-8331
US

IV. Provider business mailing address

11469 JOHN DORY WAY
JACKSONVILLE FL
32223-7373
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-4199
  • Fax: 904-633-4188
Mailing address:
  • Phone: 904-704-9192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTRN26245
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME149451
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: