Provider Demographics
NPI:1457083743
Name:ABOU HEIDAR, NASSIB FARES
Entity Type:Individual
Prefix:DR
First Name:NASSIB
Middle Name:FARES
Last Name:ABOU HEIDAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 NORTH ST APT 344
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-0009
Mailing Address - Country:US
Mailing Address - Phone:716-602-4224
Mailing Address - Fax:
Practice Address - Street 1:665 ELM ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1104
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP114715208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology