Provider Demographics
NPI:1255950440
Name:GHIASSI, MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GHIASSI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 STILLWATER CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-4370
Mailing Address - Country:US
Mailing Address - Phone:615-975-3570
Mailing Address - Fax:
Practice Address - Street 1:1 HEROES WAY
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2058
Practice Address - Country:US
Practice Address - Phone:631-548-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322416207R00000X
PAOS024395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine