Provider Demographics
NPI:1245425065
Name:NASSOUR, DIMA NASSOUR (MD)
Entity type:Individual
Prefix:
First Name:DIMA
Middle Name:NASSOUR
Last Name:NASSOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551272
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1272
Mailing Address - Country:US
Mailing Address - Phone:904-646-1987
Mailing Address - Fax:904-646-1501
Practice Address - Street 1:11555 CENTRAL PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2691
Practice Address - Country:US
Practice Address - Phone:904-646-1987
Practice Address - Fax:904-646-1501
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46109207RI0200X
FLME113964207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I445157Medicare PIN