Provider Demographics
NPI:1831220235
Name:NASSER MOUKADDEM, M.D., P.A.
Entity type:Organization
Organization Name:NASSER MOUKADDEM, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NASSER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUKADDEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-321-3915
Mailing Address - Street 1:4226 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1140
Mailing Address - Country:US
Mailing Address - Phone:727-321-3915
Mailing Address - Fax:727-328-0975
Practice Address - Street 1:4226 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1140
Practice Address - Country:US
Practice Address - Phone:727-321-3915
Practice Address - Fax:727-328-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260638100Medicaid
FL110189691OtherRAILROAD MEDICARE
FLK1534Medicare ID - Type UnspecifiedGROUP PROVIDER