Basic Information
| Provider Information | |||||||||
| NPI: | 1609000215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETER A. NASSAR, M.D., P.A. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3537 CREST ST | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320923801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042369331 | ||||||||
| FaxNumber: | 9043380533 | ||||||||
| Practice Location | |||||||||
| Address1: | 6930 BONNEVAL RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322166084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048546899 | ||||||||
| FaxNumber: | 9043380533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2009 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | NASSAR | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9042369331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | ME94669 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | ME94669 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 299886 | 01 | FL | AVMED | OTHER | 6428573 | 01 | FL | CIGNA | OTHER | 31047 | 01 | FL | BCBS OF FL | OTHER | 7329770 | 01 | FL | AETNA | OTHER | 274620400 | 05 | FL | MEDICAID | P00629712 | 01 | FL | RAILROAD MEDICARE | OTHER |