Provider Demographics
NPI:1659325165
Name:NASR, ISSAM RAFIC (MD)
Entity Type:Individual
Prefix:
First Name:ISSAM
Middle Name:RAFIC
Last Name:NASR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:SUITE 2815
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5981
Mailing Address - Country:US
Mailing Address - Phone:386-586-1810
Mailing Address - Fax:386-586-1811
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:SUITE 2815
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5981
Practice Address - Country:US
Practice Address - Phone:386-586-1850
Practice Address - Fax:386-586-1850
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2020-01-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA36550207R00000X
FLME0109365207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0493098Medicaid
IA25320OtherWELLMARK BCBS
I53212Medicare UPIN
IAI17663Medicare PIN
IAP00347201Medicare PIN