Provider Demographics
NPI:1609936558
Name:NASS, MITCHELL MARK (OD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:MARK
Last Name:NASS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:195 S COURTENAY PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4888
Mailing Address - Country:US
Mailing Address - Phone:321-454-3002
Mailing Address - Fax:321-454-2512
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:321-698-3053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35433152W00000X
FLOPC1771152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL592244423OtherTIN
FL592244423OtherTIN