Provider Demographics
NPI:1114066115
Name:AMISSAH, IMMANUEL (MD)
Entity Type:Individual
Prefix:
First Name:IMMANUEL
Middle Name:
Last Name:AMISSAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18900 N TAMIAMI TRL
Mailing Address - Street 2:STE 9
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7307
Mailing Address - Country:US
Mailing Address - Phone:239-567-1000
Mailing Address - Fax:239-567-1008
Practice Address - Street 1:540 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5368
Practice Address - Country:US
Practice Address - Phone:702-877-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2006-0432207Q00000X
WV27280208M00000X
NV17098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO53671074Medicaid