Healthcare Provider Details

I. General information

NPI: 1023071701
Provider Name (Legal Business Name): NISSIM BASSOUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 OCEAN PKWY
BROOKLYN NY
11235-6132
US

IV. Provider business mailing address

2490 OCEAN PKWY
BROOKLYN NY
11235-6132
US

V. Phone/Fax

Practice location:
  • Phone: 718-496-4607
  • Fax: 718-382-1920
Mailing address:
  • Phone: 718-496-4607
  • Fax: 718-382-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1861601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: