Provider Demographics
NPI:1558340067
Name:KOUSSA, SAMIR M (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:M
Last Name:KOUSSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:4725 N. FEDERAL HIGHWAY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-771-8000
Practice Address - Fax:954-776-3270
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 74360207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254031200Medicaid
FL44428OtherBLUE CROSS BLUE SHIELD
FL44428OtherBCBS OF FLORIDA
FL285354OtherAVMED
FL050063733OtherRAILROAD MEDICARE
FL285354OtherAVMED
G74681Medicare UPIN
FL44428OtherBLUE CROSS BLUE SHIELD