Provider Demographics
NPI:1861717514
Name:DORILAS, FANUEL (MD)
Entity type:Individual
Prefix:
First Name:FANUEL
Middle Name:
Last Name:DORILAS
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 1:312 BONTONA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2418
Mailing Address - Country:US
Mailing Address - Phone:954-478-2041
Mailing Address - Fax:954-999-0230
Practice Address - Street 1:7800 WEST OAKLAND PARK BLVD SUITE B-105
Practice Address - Street 2:FAMILY WELLNESS AND AESTHETIC CENTER LLC
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351
Practice Address - Country:US
Practice Address - Phone:954-890-3902
Practice Address - Fax:954-999-0230
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2025-03-10
Deactivation Date:2025-02-18
Deactivation Code:
Reactivation Date:2025-03-06
Provider Licenses
StateLicense IDTaxonomies
FLACN527207RA0401X, 208D00000X
GA70734208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine