Healthcare Provider Details

I. General information

NPI: 1245425065
Provider Name (Legal Business Name): DIMA NASSOUR NASSOUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11555 CENTRAL PKWY SUITE 204
JACKSONVILLE FL
32224-2691
US

IV. Provider business mailing address

PO BOX 551272
JACKSONVILLE FL
32255-1272
US

V. Phone/Fax

Practice location:
  • Phone: 904-646-1987
  • Fax: 904-646-1501
Mailing address:
  • Phone: 904-646-1987
  • Fax: 904-646-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number46109
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME113964
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: