Healthcare Provider Details

I. General information

NPI: 1417951013
Provider Name (Legal Business Name): JOSE AGUSTIN NASSAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 CRUZ ORTIZ STELLA AVE.
HUMACAO PR
00791
US

IV. Provider business mailing address

PO BOX 9132
HUMACAO PR
00792-9132
US

V. Phone/Fax

Practice location:
  • Phone: 787-852-0920
  • Fax: 787-852-6685
Mailing address:
  • Phone: 787-852-0920
  • Fax: 787-852-6685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number2993
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2993
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: