1609000215 NPI number — PETER A. NASSAR, M.D., P.A.

Table of content: (NPI 1609000215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609000215 NPI number — PETER A. NASSAR, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER A. NASSAR, M.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1609000215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3537 CREST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32092-3801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-236-9331
Provider Business Mailing Address Fax Number:
904-338-0533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6930 BONNEVAL RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-6084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-854-6899
Provider Business Practice Location Address Fax Number:
904-338-0533
Provider Enumeration Date:
05/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
NASSAR
Authorized Official First Name:
PETER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-236-9331

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  ME94669 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: ME94669 , 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: 299886 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6428573 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 31047 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7329770 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 274620400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00629712 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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