Provider Demographics
NPI:1639117252
Name:ELMANSOURY, ABDELNASSER G (MD PA)
Entity Type:Individual
Prefix:
First Name:ABDELNASSER
Middle Name:G
Last Name:ELMANSOURY
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17222 HOSPITAL BLVD
Mailing Address - Street 2:SUITE 238
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-8925
Mailing Address - Country:US
Mailing Address - Phone:352-345-4804
Mailing Address - Fax:352-593-4918
Practice Address - Street 1:17222 HOSPITAL BLVD
Practice Address - Street 2:SUITE 238
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8925
Practice Address - Country:US
Practice Address - Phone:352-345-4804
Practice Address - Fax:352-593-4918
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064736174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373642300Medicaid
FL373642300Medicaid