Provider Demographics
NPI:1053728436
Name:DASA, OSAMA (MD)
Entity type:Individual
Prefix:
First Name:OSAMA
Middle Name:
Last Name:DASA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1136
Mailing Address - Country:US
Mailing Address - Phone:419-322-6509
Mailing Address - Fax:352-265-0379
Practice Address - Street 1:2000 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608
Practice Address - Country:US
Practice Address - Phone:419-322-6509
Practice Address - Fax:352-265-0379
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME136087207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025123700Medicaid