Provider Demographics
NPI:1457380388
Name:NISSAN, OFER (RPT)
Entity Type:Individual
Prefix:MR
First Name:OFER
Middle Name:
Last Name:NISSAN
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 1:5717 DEREK AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2413
Mailing Address - Country:US
Mailing Address - Phone:941-926-2909
Mailing Address - Fax:
Practice Address - Street 1:5717 DEREK AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2413
Practice Address - Country:US
Practice Address - Phone:941-926-2909
Practice Address - Fax:941-926-0094
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7380OtherBLUE CROSS/BLUE SHIELD
FLY7380CMedicare ID - Type UnspecifiedMEDICARE NO.
FLY7380OtherBLUE CROSS/BLUE SHIELD