Provider Demographics
NPI:1235335324
Name:NISSIM, LAHAV (MD)
Entity Type:Individual
Prefix:DR
First Name:LAHAV
Middle Name:
Last Name:NISSIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LAVI
Other - Middle Name:
Other - Last Name:NISSIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0198
Practice Address - Fax:602-933-2492
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ783502085R0204X
AZ416792085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ615187Medicaid
AZ18847Medicare UPIN
AZ146443Medicare PIN