Provider Demographics
NPI:1609000215
Name:PETER A. NASSAR, M.D., P.A.
Entity Type:Organization
Organization Name:PETER A. NASSAR, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:NASSAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-236-9331
Mailing Address - Street 1:3537 CREST ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3801
Mailing Address - Country:US
Mailing Address - Phone:904-236-9331
Mailing Address - Fax:904-338-0533
Practice Address - Street 1:6930 BONNEVAL RD
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6084
Practice Address - Country:US
Practice Address - Phone:904-854-6899
Practice Address - Fax:904-338-0533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94669207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL299886OtherAVMED
FL6428573OtherCIGNA
FL31047OtherBCBS OF FL
FL7329770OtherAETNA
FL274620400Medicaid
FLP00629712OtherRAILROAD MEDICARE
FL31047ZMedicare PIN
FL31047OtherBCBS OF FL