Healthcare Provider Details

I. General information

NPI: 1508306150
Provider Name (Legal Business Name): FADY HANNA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 VAN DYKE RD
LUTZ FL
33558-8005
US

IV. Provider business mailing address

5085 NIGHT STAR TRL
ODESSA FL
33556-4576
US

V. Phone/Fax

Practice location:
  • Phone: 918-599-1000
  • Fax:
Mailing address:
  • Phone: 727-858-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS17387
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: