Basic Information
| Provider Information | |||||||||
| NPI: | 1194740993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABOUSHAAR | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | HASSAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 WELLS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320732982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9042824117 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 KINGSLEY AVE | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042640264 | ||||||||
| FaxNumber: | 9042782437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME65257 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 376161400 | 05 | FL | MEDICAID |