Basic Information
| Provider Information | |||||||||
| NPI: | 1356972798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDREW NASSERI MD INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4978 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953524978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095754575 | ||||||||
| FaxNumber: | 2095754598 | ||||||||
| Practice Location | |||||||||
| Address1: | 4077 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192607101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2020 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOLE | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2095754575 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | CB245859 | 05 | CA | MEDICAID |