Basic Information
Provider Information | |||||||||
NPI: | 1629157243 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NASSAR | ||||||||
FirstName: | PETER | ||||||||
MiddleName: | ANTON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 43667 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322033667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043983760 | ||||||||
FaxNumber: | 9043380533 | ||||||||
Practice Location | |||||||||
Address1: | 6930 BONNEVAL RD | ||||||||
Address2: | SUITE #2 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322166012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9048546899 | ||||||||
FaxNumber: | 9043380533 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2006 | ||||||||
LastUpdateDate: | 11/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | ME94669 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 274620400 | 05 | FL |   | MEDICAID | 593385828 | 01 | FL | UNITED HEALTHCARE | OTHER | 29986 | 01 | FL | AV MED | OTHER | 7329770 | 01 | FL | AETNA | OTHER | 31047 | 01 | FL | BCBS | OTHER |