Provider Demographics
NPI:1528498276
Name:ABDALLA, ABDELAZIM
Entity type:Individual
Prefix:
First Name:ABDELAZIM
Middle Name:
Last Name:ABDALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 BAY 43RD ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-6708
Mailing Address - Country:US
Mailing Address - Phone:646-358-0105
Mailing Address - Fax:866-670-4824
Practice Address - Street 1:228 BAY 43RD ST
Practice Address - Street 2:APT. 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-6708
Practice Address - Country:US
Practice Address - Phone:646-358-0105
Practice Address - Fax:866-670-4824
Is Sole Proprietor?:No
Enumeration Date:2013-11-16
Last Update Date:2013-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02685321Medicaid