Healthcare Provider Details

I. General information

NPI: 1144760059
Provider Name (Legal Business Name): KHLAED DIAB MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 FAIRWAY DR
PLANTATION FL
33317-4438
US

IV. Provider business mailing address

828 FAIRWAY DR
PLANTATION FL
33317-4438
US

V. Phone/Fax

Practice location:
  • Phone: 954-947-1788
  • Fax:
Mailing address:
  • Phone: 954-947-1788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME125048
License Number StateFL

VIII. Authorized Official

Name: DR. KHALED DIAB
Title or Position: PROVIDE/OWNER
Credential: M.D.
Phone: 954-947-1788