Provider Demographics
NPI:1114025301
Name:AL-MOUSILY, FARIS M (MD)
Entity type:Individual
Prefix:DR
First Name:FARIS
Middle Name:M
Last Name:AL-MOUSILY
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 1:3021 W EAU GALLIE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7005
Mailing Address - Country:US
Mailing Address - Phone:321-275-5444
Mailing Address - Fax:321-275-3799
Practice Address - Street 1:3021 W EAU GALLIE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7005
Practice Address - Country:US
Practice Address - Phone:321-275-5444
Practice Address - Fax:321-275-3799
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME708092080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2506050000Medicaid
FL31303XMedicare PIN
31303ZMedicare PIN
G35961Medicare UPIN