Basic Information
| Provider Information | |||||||||
| NPI: | 1558370411 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDULFATTAH | ||||||||
| FirstName: | QAHTAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14690 SPRING HILL DR | ||||||||
| Address2: | SUITE 100 ATTN:CREDENTIALING | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346098102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527990046 | ||||||||
| FaxNumber: | 3526062857 | ||||||||
| Practice Location | |||||||||
| Address1: | 11323 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346135407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525968344 | ||||||||
| FaxNumber: | 3525972898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | ME92671 | FL | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01426390 | 01 | FL | RAILROAD MCR LINKED TO GRP#DR6927 | OTHER | 311869 | 01 | FL | AVMED | OTHER | 316584 | 01 | FL | WELLCARE | OTHER | 000238700 | 05 | FL | MEDICAID | 03396 | 01 | FL | BCBS OF FL | OTHER |