Provider Demographics
NPI:1063746873
Name:RADWAN, MOHAMED OMAR (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:OMAR
Last Name:RADWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1325 SAN MARCO BLVD
Mailing Address - Street 2:REID BUILDING, STE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8568
Mailing Address - Country:US
Mailing Address - Phone:904-253-6910
Mailing Address - Fax:904-253-6964
Practice Address - Street 1:1325 SAN MARCO BLVD
Practice Address - Street 2:REID BUILDING, STE 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8568
Practice Address - Country:US
Practice Address - Phone:904-253-6910
Practice Address - Fax:904-253-6964
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110119207R00000X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003911100Medicaid
FL936658OtherAETNA
FLP01364661OtherMEDICARE RAILROAD
FL59-3385828OtherTAX ID FOR OTHER INSURANCES
FL14H00OtherBCBS
FL348958OtherAVMED
FLFH540XMedicare PIN