Basic Information
| Provider Information | |||||||||
| NPI: | 1639102049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAFEZ | ||||||||
| FirstName: | OSAMA | ||||||||
| MiddleName: | IBRAHIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12902 USF MAGNOLIA DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137458486 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12902 USF MAGNOLIA DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137458486 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME93664 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 16643 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 273082100 | 05 | FL | MEDICAID |