Provider Demographics
NPI:1427080589
Name:FADUL, JAMAL (MD)
Entity type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:FADUL
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:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20738-0569
Mailing Address - Country:US
Mailing Address - Phone:301-441-4400
Mailing Address - Fax:
Practice Address - Street 1:6201 GREENBELT RD
Practice Address - Street 2:SUITE M-16
Practice Address - City:BERWYN HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20740-2354
Practice Address - Country:US
Practice Address - Phone:301-441-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD53745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H08180Medicare UPIN
00A031M45/G00445Medicare ID - Type Unspecified