Basic Information
| Provider Information | |||||||||
| NPI: | 1407385636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HABHAB | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | NIZAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11512 LAKE MEAD AVE UNIT 534 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046422222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11512 LAKE MEAD AVE UNIT 534 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046422222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2017 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 4301112050 | MI | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 4351031718 | MI | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | MD473679 | PA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0120X | ME155829 | FL | Y |
No ID Information.