Provider Demographics
NPI:1144592007
Name:ABDELNASSER ELMANSOURY MD PA
Entity Type:Organization
Organization Name:ABDELNASSER ELMANSOURY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABDELNASSER
Authorized Official - Middle Name:GAMAL
Authorized Official - Last Name:ELMANSOURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-345-4804
Mailing Address - Street 1:17222 HOSPITAL BLVD
Mailing Address - Street 2:SUITE 238
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-8925
Mailing Address - Country:US
Mailing Address - Phone:352-345-4804
Mailing Address - Fax:352-593-4918
Practice Address - Street 1:17222 HOSPITAL BLVD
Practice Address - Street 2:SUITE 238
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8925
Practice Address - Country:US
Practice Address - Phone:352-345-4804
Practice Address - Fax:352-593-4918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639117252Medicare PIN