Healthcare Provider Details

I. General information

NPI: 1477532463
Provider Name (Legal Business Name): FAWZI SOUHEIL FARHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 ASHOURIAN AVE STE 213
SAINT AUGUSTINE FL
32092-5107
US

IV. Provider business mailing address

206 ASHOURIAN AVE STE 213
SAINT AUGUSTINE FL
32092-5107
US

V. Phone/Fax

Practice location:
  • Phone: 904-990-0777
  • Fax: 888-464-0609
Mailing address:
  • Phone: 904-990-0777
  • Fax: 888-464-0609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberI40882
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME92741
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: