Basic Information
| Provider Information | |||||||||
| NPI: | 1073591269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISKANDER | ||||||||
| FirstName: | ENAS | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GERGES | ||||||||
| OtherFirstName: | ENAS | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264590 | ||||||||
| FaxNumber: | 3862263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 1688 W GRANADA BLVD STE 2A1 | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864254466 | ||||||||
| FaxNumber: | 3864254461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME0057495 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | ME7495 | FL | N | Allopathic & Osteopathic Physicians | General Practice | 208000000X | ME57495 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 054122201 | 05 | FL | MEDICAID | 12487 | 01 | FL | BLUE CROSS BLUE SHIELD FL | OTHER |