Healthcare Provider Details

I. General information

NPI: 1982199634
Provider Name (Legal Business Name): CHAIM NISSEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHAIM LEIB BETZALEL NISSEL

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7481 W OAKLAND PARK BLVD STE 100
TAMARAC FL
33319-4985
US

IV. Provider business mailing address

1065 NE 125TH ST STE 300
NORTH MIAMI FL
33161-5833
US

V. Phone/Fax

Practice location:
  • Phone: 954-771-7743
  • Fax: 954-771-7748
Mailing address:
  • Phone: 888-852-6672
  • Fax: 305-891-4228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4504
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS15435
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1021719
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: