Provider Demographics
NPI:1568462083
Name:BARSOUM, NAGEH S (MD)
Entity Type:Individual
Prefix:DR
First Name:NAGEH
Middle Name:S
Last Name:BARSOUM
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 1:3260 MURRELL RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4407
Mailing Address - Country:US
Mailing Address - Phone:321-632-7520
Mailing Address - Fax:321-632-8092
Practice Address - Street 1:3260 MURRELL RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-4407
Practice Address - Country:US
Practice Address - Phone:321-632-7520
Practice Address - Fax:321-632-8092
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81897208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1867XMedicare PIN
FLH98623Medicare UPIN
FLU1867XMedicare PIN
FLU1867YMedicare PIN
FLH98623Medicare UPIN
FL264156900Medicaid