Provider Demographics
NPI:1861442857
Name:NAGIB, ISSAC (RPT)
Entity Type:Individual
Prefix:
First Name:ISSAC
Middle Name:
Last Name:NAGIB
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4322
Mailing Address - Country:US
Mailing Address - Phone:863-676-8300
Mailing Address - Fax:863-676-1300
Practice Address - Street 1:1342 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4322
Practice Address - Country:US
Practice Address - Phone:863-676-8300
Practice Address - Fax:863-676-1300
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT3913174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888102200Medicaid
FL888102200Medicaid
FLP66969Medicare UPIN