Healthcare Provider Details

I. General information

NPI: 1649430802
Provider Name (Legal Business Name): SAMIR K KASSICIEH, DO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 BRIDGE BLVD SW SUITE A
ALBUQUERQUE NM
87105-3765
US

IV. Provider business mailing address

PO BOX 12435
ALBUQUERQUE NM
87195-0435
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-0212
  • Fax: 505-877-0139
Mailing address:
  • Phone: 505-877-0212
  • Fax: 505-877-0139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMIR K KASSICIEH
Title or Position: OWNER
Credential: D. O.
Phone: 505-877-0212