Provider Demographics
NPI:1992731327
Name:NASSIFF, MARIE D (MD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:D
Last Name:NASSIFF
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 1:4665 WERY RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-9102
Mailing Address - Country:US
Mailing Address - Phone:920-217-7868
Mailing Address - Fax:
Practice Address - Street 1:4665 WERY RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-9102
Practice Address - Country:US
Practice Address - Phone:920-866-1394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32906207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31784400Medicaid
WIF18316Medicare UPIN
WI005307650Medicare ID - Type Unspecified