Healthcare Provider Details

I. General information

NPI: 1841166451
Provider Name (Legal Business Name): DA'AD ABDALLA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0006
US

IV. Provider business mailing address

1120 15TH ST
AUGUSTA GA
30912-0006
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-9442
  • Fax:
Mailing address:
  • Phone: 706-721-9442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number112419
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: