Healthcare Provider Details

I. General information

NPI: 1215188743
Provider Name (Legal Business Name): FATAN JAAFAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 03/11/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N WYMORE RD STE B
WINTER PARK FL
32789-2823
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 407-613-2473
  • Fax: 407-613-2474
Mailing address:
  • Phone: 407-613-2473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME110851
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: