Healthcare Provider Details

I. General information

NPI: 1801007646
Provider Name (Legal Business Name): JAMAL SAMIH KSAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8791 CONFERENCE DR SUITE 1
FORT MYERS FL
33919-5822
US

IV. Provider business mailing address

8791 CONFERENCE DR SUITE 1
FORT MYERS FL
33919-5822
US

V. Phone/Fax

Practice location:
  • Phone: 239-938-3506
  • Fax:
Mailing address:
  • Phone: 239-938-3506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME106342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: