Provider Demographics
NPI:1326043209
Name:NASSIF, MARIAM N (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:N
Last Name:NASSIF
Suffix:
Gender:F
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-2650
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE 3490
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6193751-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00348605OtherMEDICARE RAILROAD
BN8566318OtherDEA NUMBER
I03106Medicare UPIN
UT000063442Medicare PIN
5M764Medicare ID - Type Unspecified