Basic Information
| Provider Information | |||||||||
| NPI: | 1154522175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULTAN | ||||||||
| FirstName: | MOHAMED | ||||||||
| MiddleName: | BADR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ABO ASSAD SULTAN | ||||||||
| OtherFirstName: | MOHAMED | ||||||||
| OtherMiddleName: | BADR | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5992 BERRYHILL RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MILTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325701013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506265324 | ||||||||
| FaxNumber: | 8506265124 | ||||||||
| Practice Location | |||||||||
| Address1: | 5992 BERRYHILL RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MILTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325701013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506265324 | ||||||||
| FaxNumber: | 8506265124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 28182 | AL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | ME108765 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | ET708Z | 01 | MEDICARE PTAN | OTHER | 003455100 | 05 | FL | MEDICAID |