Provider Demographics
NPI:1447246392
Name:NISSIM, KENNETH RICHARD (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:RICHARD
Last Name:NISSIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1120 NW 14TH ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-2107
Mailing Address - Country:US
Mailing Address - Phone:305-243-3564
Mailing Address - Fax:305-243-2009
Practice Address - Street 1:1253 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2201
Practice Address - Country:US
Practice Address - Phone:779-696-9201
Practice Address - Fax:815-397-9667
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2024-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME85561207YS0012X, 207Y00000X
IL036170811207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2675617-00Medicaid
FL2675617-00Medicaid
FLU0396YMedicare PIN