Provider Demographics
NPI:1053367904
Name:HAMEROFF, NATHAN MORRIS (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:MORRIS
Last Name:HAMEROFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1190 80TH STREET CT S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2725
Mailing Address - Country:US
Mailing Address - Phone:727-384-0395
Mailing Address - Fax:727-343-5552
Practice Address - Street 1:5880 49TH ST N
Practice Address - Street 2:SUITE 104
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2150
Practice Address - Country:US
Practice Address - Phone:727-521-9552
Practice Address - Fax:727-528-4757
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300075305OtherRAILROAD MEDICARE
FL52796OtherBLUE CROSS BLUE SHIELD
FL056422200Medicaid
FLD56266Medicare UPIN
FL056422200Medicaid