Healthcare Provider Details

I. General information

NPI: 1114920030
Provider Name (Legal Business Name): ISSA ELGENDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 OLIVER ST STE B
FAYETTEVILLE NC
28304-4449
US

IV. Provider business mailing address

PO BOX 40908
FAYETTEVILLE NC
28309-0908
US

V. Phone/Fax

Practice location:
  • Phone: 910-609-4801
  • Fax: 910-609-5406
Mailing address:
  • Phone: 910-609-6448
  • Fax: 910-609-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200000049
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: