Healthcare Provider Details

I. General information

NPI: 1457083743
Provider Name (Legal Business Name): NASSIB F ABOU HEIDAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-1104
US

IV. Provider business mailing address

PO BOX 749112
ATLANTA GA
30374-9112
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-3627
  • Fax:
Mailing address:
  • Phone: 434-295-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberP114715
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101283602
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: