Provider Demographics
NPI:1871753905
Name:NASRALLAH, FADY S (MD)
Entity type:Individual
Prefix:
First Name:FADY
Middle Name:S
Last Name:NASRALLAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 85466
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92186-5466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9888 GENESEE AVE
Practice Address - Street 2:LJ 601
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-626-6353
Practice Address - Fax:858-626-6354
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11176208600000X, 2086S0102X, 2086S0127X
CAA123254208600000X, 2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871753905Medicaid
ND10408Medicaid
CAHA868AMedicare PIN
NDN714312Medicare PIN