Healthcare Provider Details

I. General information

NPI: 1780649194
Provider Name (Legal Business Name): NOVA SOUTHEASTERN UNIVERSITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR ASSEMBLY BUILDING II, SUITE 202
DAVIE FL
33328-2018
US

IV. Provider business mailing address

3200 S UNIVERSITY DR ASSEMBLY BUILDING II, SUITE 202
DAVIE FL
33328-2018
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-4399
  • Fax: 954-262-1172
Mailing address:
  • Phone: 954-262-4399
  • Fax: 954-262-1172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS2443
License Number StateFL

VIII. Authorized Official

Name: ROBERT S OLLER
Title or Position: CEO
Credential: D.O.
Phone: 954-262-4399