Provider Demographics
NPI:1427157494
Name:YASSA, SAMIR K (MD)
Entity type:Individual
Prefix:
First Name:SAMIR
Middle Name:K
Last Name:YASSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S COURTENAY PARKWAY
Mailing Address - Street 2:BLDG B
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952
Mailing Address - Country:US
Mailing Address - Phone:321-453-5326
Mailing Address - Fax:321-452-8507
Practice Address - Street 1:245 S CURTENAY PARKWAY
Practice Address - Street 2:BLDG B
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-453-5326
Practice Address - Fax:321-452-8507
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90329207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270784500Medicaid
7709220OtherAETNA
P00145735OtherRR MEDICARE
7709220OtherAETNA
H06660Medicare UPIN