Healthcare Provider Details

I. General information

NPI: 1114189073
Provider Name (Legal Business Name): JAVERIA NASIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 N COUNTRY RD
PORT JEFFERSON NY
11777-2119
US

IV. Provider business mailing address

75 N COUNTRY RD
PORT JEFFERSON NY
11777-2119
US

V. Phone/Fax

Practice location:
  • Phone: 631-473-1320
  • Fax: 631-686-7972
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number261711
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number261711
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: