1508882135 NPI number — DR. NASSER M KAZMOUZ MD

Table of content: DR. NASSER M KAZMOUZ MD (NPI 1508882135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508882135 NPI number — DR. NASSER M KAZMOUZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAZMOUZ
Provider First Name:
NASSER
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508882135
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
323 S MINNESOTA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROOKSTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56716-1601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2727 W DR MARTIN LUTHER KING JR BLVD STE 800
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33607-6065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-873-0000
Provider Business Practice Location Address Fax Number:
813-873-3659
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  48659 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME111513 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 48659 . This is a "STATE LICENCE NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 115981700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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