Healthcare Provider Details

I. General information

NPI: 1104945872
Provider Name (Legal Business Name): BASANT M FARGHALY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 US HIGHWAY 1 S STE 4
ST AUGUSTINE FL
32086-6310
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 904-810-8063
  • Fax: 904-621-9230
Mailing address:
  • Phone: 904-810-8063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME97900
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: