Healthcare Provider Details

I. General information

NPI: 1164717054
Provider Name (Legal Business Name): GIOVANNI FADDOUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2011
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 HACKETT BLVD
ALBANY NY
12208-3462
US

IV. Provider business mailing address

25 HACKETT BLVD
ALBANY NY
12208-3462
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-5176
  • Fax: 518-262-5573
Mailing address:
  • Phone: 518-262-5176
  • Fax: 518-262-5573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number302711
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: