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General NPI Number Information
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NPI Number | 1558370411
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Entity Type | Individual
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Provider Name | QAHTAN A ABDULFATTAH MD
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Gender | Male
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Dates
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Enumeration Date | 08/07/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 11323 CORTEZ BLVD
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City | BROOKSVILLE
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State | FL
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Zip | 34613-5407
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Country | US
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Telephone | 352-596-8344
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Fax | 352-597-2898
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Provider Business Mailing Address
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Address Line | 14690 SPRING HILL DR SUITE 100 ATTN:CREDENTIALING
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City | SPRING HILL
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State | FL
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Zip | 34609-8102
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Country | US
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Telephone | 352-799-0046
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Fax | 352-606-2857
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204C00000X
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Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
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License Number | ME92671
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License Number State | FL
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