Individual
KENNETH RICHARD NISSIM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1253 N ALPINE RD, ROCKFORD, IL 61107-2201
(779) 696-9201
(815) 397-9667
Mailing address
1120 NW 14TH ST, 5TH FLOOR, MIAMI, FL 33136-2107
(305) 243-3564
(305) 243-2009
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
ME85561
FL
207YS0012X
Sleep Medicine (Otolaryngology) Physician
ME85561
FL
207YX0007X
Plastic Surgery within the Head & Neck (Otolaryngology) Physician
Primary
036170811
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2675617-00
—
FL
Enumeration date
09/26/2005
Last updated
12/11/2024
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