Provider Demographics
NPI:1447477484
Name:FAWAZ MEDICAL & SURGICAL CLINIC
Entity type:Organization
Organization Name:FAWAZ MEDICAL & SURGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:S
Authorized Official - Last Name:FAWAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-951-4638
Mailing Address - Street 1:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-0075
Mailing Address - Country:US
Mailing Address - Phone:850-951-4638
Mailing Address - Fax:850-951-4554
Practice Address - Street 1:4417 US HWY 331 S
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPGS
Practice Address - State:FL
Practice Address - Zip Code:32435-6703
Practice Address - Country:US
Practice Address - Phone:850-951-4638
Practice Address - Fax:850-951-4554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8303207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL51934Medicare ID - Type Unspecified