Provider Demographics
NPI:1316908353
Name:FLORIDA ENT ADULT & PEDIATRIC PA
Entity type:Organization
Organization Name:FLORIDA ENT ADULT & PEDIATRIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:FADHLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-343-9006
Mailing Address - Street 1:1162 CYPRESS GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7560
Mailing Address - Country:US
Mailing Address - Phone:407-343-9006
Mailing Address - Fax:407-343-0999
Practice Address - Street 1:1162 CYPRESS GLEN CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7560
Practice Address - Country:US
Practice Address - Phone:407-343-9006
Practice Address - Fax:407-343-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0077191207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAB304OtherMEDICARE PTAN
FLAB304OtherMEDICARE PTAN