Basic Information
| Provider Information | |||||||||
| NPI: | 1447246392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISSIM | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 NW 14TH ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331362107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052433564 | ||||||||
| FaxNumber: | 3052432009 | ||||||||
| Practice Location | |||||||||
| Address1: | 8932 SW 97TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331761936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052703740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | ME85561 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207YS0012X | ME85561 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2675617-00 | 05 | FL | MEDICAID |