Provider Demographics
NPI:1720628704
Name:HADDAD, HISHAM
Entity type:Individual
Prefix:
First Name:HISHAM
Middle Name:
Last Name:HADDAD
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 1:3158 PRIMEBEEF WAY
Mailing Address - Street 2:
Mailing Address - City:DUKE FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3158 PRIMEBEEF WAY
Practice Address - Street 2:
Practice Address - City:DUKE FIELD
Practice Address - State:FL
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:850-883-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX29005393OtherMILITARY