Provider Demographics
NPI:1124008883
Name:MOUKADDEM, NASSER A (MD)
Entity Type:Individual
Prefix:
First Name:NASSER
Middle Name:A
Last Name:MOUKADDEM
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 1:4226 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1140
Mailing Address - Country:US
Mailing Address - Phone:727-321-3915
Mailing Address - Fax:
Practice Address - Street 1:4226 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1140
Practice Address - Country:US
Practice Address - Phone:727-321-3915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLME0071447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110189691OtherRAILROAD MEDICARE
FL254197100Medicaid
FL110189691OtherRAILROAD MEDICARE
FL254197100Medicaid