Basic Information
Provider Information | |||||||||
NPI: | 1265480289 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HASAN | ||||||||
FirstName: | NASIR | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 805 CENTURY MEDICAL DRIVE | ||||||||
Address2: | CREDENTIALING OFFICE | ||||||||
City: | TITUSVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 327963747 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3212686264 | ||||||||
FaxNumber: | 3217248749 | ||||||||
Practice Location | |||||||||
Address1: | 951 N WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | TITUSVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 327963747 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3212686111 | ||||||||
FaxNumber: | 3212686360 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 06/14/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME75157 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | ME75157 | FL | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 275900400 | 05 | FL |   | MEDICAID |