Provider Demographics
NPI:1891966438
Name:ABTAHI, RASSOUL
Entity Type:Individual
Prefix:MR
First Name:RASSOUL
Middle Name:
Last Name:ABTAHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4999 W 8TH AVE
Mailing Address - Street 2:#6
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3409
Mailing Address - Country:US
Mailing Address - Phone:305-821-0100
Mailing Address - Fax:305-821-0808
Practice Address - Street 1:4999 W 8TH AVE
Practice Address - Street 2:#6
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3409
Practice Address - Country:US
Practice Address - Phone:305-821-0100
Practice Address - Fax:305-821-0808
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0004946174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL881213600Medicaid
FL881213600Medicaid