Provider Demographics
NPI:1154522175
Name:SULTAN, MOHAMED BADR (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:BADR
Last Name:SULTAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHAMED
Other - Middle Name:BADR
Other - Last Name:ABO ASSAD SULTAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5992 BERRYHILL RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-1013
Mailing Address - Country:US
Mailing Address - Phone:850-626-5324
Mailing Address - Fax:850-626-5124
Practice Address - Street 1:5992 BERRYHILL RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-1013
Practice Address - Country:US
Practice Address - Phone:850-626-5324
Practice Address - Fax:850-626-5124
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL281822084N0400X
FLME1087652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ET708ZOtherMEDICARE PTAN
FL003455100Medicaid