Provider Demographics
NPI:1063408771
Name:ATALLA, FOUAD VICTOR (MD)
Entity type:Individual
Prefix:
First Name:FOUAD
Middle Name:VICTOR
Last Name:ATALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 ASHLEY ST STE 303
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-2451
Mailing Address - Country:US
Mailing Address - Phone:270-796-8960
Mailing Address - Fax:270-842-5683
Practice Address - Street 1:1048 ASHLEY ST STE 303
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2451
Practice Address - Country:US
Practice Address - Phone:270-796-8960
Practice Address - Fax:270-842-5683
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY337442086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64337447Medicaid
KY64337447Medicaid
KY64337447Medicaid