Healthcare Provider Details

I. General information

NPI: 1053390047
Provider Name (Legal Business Name): BASSAM RIZK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6067 KENNERLY RD
JACKSONVILLE FL
32216-4305
US

IV. Provider business mailing address

PO BOX 63124
CHARLOTTE NC
28263-3124
US

V. Phone/Fax

Practice location:
  • Phone: 904-731-3131
  • Fax:
Mailing address:
  • Phone: 904-731-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME21343
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME64544
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: