Healthcare Provider Details

I. General information

NPI: 1326043209
Provider Name (Legal Business Name): MARIAM N NASSIF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD STE 3490
OGDEN UT
84403-3271
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-2650
  • Fax:
Mailing address:
  • Phone: 801-387-2650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number6193751-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: