Basic Information
| Provider Information | |||||||||
| NPI: | 1710596861 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALTANTAWI | ||||||||
| FirstName: | ABDALLAH | ||||||||
| MiddleName: | MAHMOUD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4870 DEER LAKE DR E FL 32246 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322466300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046334199 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 841 PRUDENTIAL DR STE 1130 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046334199 | ||||||||
| FaxNumber: | 9046334188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2020 | ||||||||
| LastUpdateDate: | 07/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 31948 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.