Provider Demographics
NPI:1144216664
Name:NISENBAUM, ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:NISENBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9575 BARLETTA WINDS PT
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-9712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3319 STATE ROAD 7
Practice Address - Street 2:102
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8094
Practice Address - Country:US
Practice Address - Phone:561-333-4000
Practice Address - Fax:561-333-8851
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6753207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250058200Medicaid
F88071Medicare UPIN