Healthcare Provider Details

I. General information

NPI: 1023647724
Provider Name (Legal Business Name): BAHA ALDEEN BANI FAWWAZ MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE STE 235
ORLANDO FL
32804-4659
US

IV. Provider business mailing address

2415 N ORANGE AVE STE 200
ORLANDO FL
32804-5505
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-7270
  • Fax:
Mailing address:
  • Phone: 407-303-7270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number158656
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number158656
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: