Healthcare Provider Details

I. General information

NPI: 1578797676
Provider Name (Legal Business Name): ABDO BACHOURA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17270 SE 109TH TERRACE RD
SUMMERFIELD FL
34491-9015
US

IV. Provider business mailing address

HQ101 UNIV OF KY 800 ROSE ST
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 352-336-6000
  • Fax:
Mailing address:
  • Phone: 617-800-3390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME141396
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberME141396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: