Provider Demographics
NPI:1134434764
Name:ABDO J. FADDOUL, M.D. A PROF CORP
Entity type:Organization
Organization Name:ABDO J. FADDOUL, M.D. A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABDO
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FADDOUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-786-3100
Mailing Address - Street 1:2 MEDICAL PLAZA
Mailing Address - Street 2:SUITE 285
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-786-3100
Mailing Address - Fax:916-786-9433
Practice Address - Street 1:2 MEDICAL PLAZA
Practice Address - Street 2:SUITE 285
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-786-3100
Practice Address - Fax:916-786-9433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41062208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A416020Medicaid
CA00A416020Medicaid