Provider Demographics
NPI:1508882135
Name:KAZMOUZ, NASSER M (MD)
Entity Type:Individual
Prefix:DR
First Name:NASSER
Middle Name:M
Last Name:KAZMOUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S MINNESOTA ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD STE 800
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6065
Practice Address - Country:US
Practice Address - Phone:813-873-0000
Practice Address - Fax:813-873-3659
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48659207Q00000X
FLME111513207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN48659OtherSTATE LICENCE NUMBER
MN080015476Medicare PIN
I57786Medicare UPIN
MN080015177Medicare PIN
MN48659OtherSTATE LICENCE NUMBER
MSC02171Medicare PIN