Provider Demographics
NPI:1033558630
Name:TABASSOM, AYESHA
Entity type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:TABASSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4422
Mailing Address - Country:US
Mailing Address - Phone:386-310-2160
Mailing Address - Fax:386-310-2106
Practice Address - Street 1:222 S PENINSULA DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-4422
Practice Address - Country:US
Practice Address - Phone:386-310-2160
Practice Address - Fax:386-310-2106
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312453207P00000X, 207Q00000X
FLME166083207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine