Healthcare Provider Details

I. General information

NPI: 1811757990
Provider Name (Legal Business Name): JONATHAN FAKHRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

4681 SW LONG BAY DR
PALM CITY FL
34990-8811
US

V. Phone/Fax

Practice location:
  • Phone: 305-355-1122
  • Fax:
Mailing address:
  • Phone: 772-233-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: