Healthcare Provider Details

I. General information

NPI: 1609210665
Provider Name (Legal Business Name): ABDIMOMUN IULDASHEV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

86 W UNDERWOOD ST MP 80
ORLANDO FL
32806-2008
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1771
  • Fax:
Mailing address:
  • Phone: 888-912-3648
  • Fax: 321-841-4085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME128107
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME128107
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: