Basic Information
Provider Information | |||||||||
NPI: | 1013215854 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ABANDEH | ||||||||
FirstName: | FOAD | ||||||||
MiddleName: | I. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MBBS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
Address2: |   | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080534197 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563550340 | ||||||||
FaxNumber: | 8563550330 | ||||||||
Practice Location | |||||||||
Address1: | 1001 BRIGGS RD STE 250 | ||||||||
Address2: |   | ||||||||
City: | MOUNT LAUREL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080544111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8568667466 | ||||||||
FaxNumber: | 8568669088 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2011 | ||||||||
LastUpdateDate: | 06/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | MD461213 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 25MA11097500 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | 1013215854 | 05 | VA |   | MEDICAID | 103315220-0001 | 05 | PA |   | MEDICAID |