Provider Demographics
NPI:1912163866
Name:ASHAMALLA, FADY
Entity type:Individual
Prefix:
First Name:FADY
Middle Name:
Last Name:ASHAMALLA
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 1:42725 HIGHWAY 27
Mailing Address - Street 2:STE 202
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-6821
Mailing Address - Country:US
Mailing Address - Phone:407-647-1781
Mailing Address - Fax:
Practice Address - Street 1:42725 HIGHWAY 27
Practice Address - Street 2:STE 202
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-6821
Practice Address - Country:US
Practice Address - Phone:407-647-1781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1171752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry