Healthcare Provider Details

I. General information

NPI: 1497249692
Provider Name (Legal Business Name): JALIL NASIBLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5189
US

IV. Provider business mailing address

3500 N BROAD ST
PHILADELPHIA PA
19140-4106
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-4353
  • Fax: 215-707-2781
Mailing address:
  • Phone: 215-707-3411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberMD476462
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: