Healthcare Provider Details

I. General information

NPI: 1821261892
Provider Name (Legal Business Name): JIBRAN NASEER M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RASPBERRY RD
BLOOMINGTON IL
61704-2816
US

IV. Provider business mailing address

11 RASPBERRY RD
BLOOMINGTON IL
61704-2816
US

V. Phone/Fax

Practice location:
  • Phone: 517-759-6974
  • Fax:
Mailing address:
  • Phone: 517-759-6974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-128203
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: