Healthcare Provider Details

I. General information

NPI: 1083134555
Provider Name (Legal Business Name): ENAS ABDALLAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ENAS ABDALLAH MD

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 09/02/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

PO BOX 198441
ATLANTA GA
30384-8441
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-4673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number4301112630
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: