Basic Information
| Provider Information | |||||||||
| NPI: | 1902907116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HASANAT | ||||||||
| FirstName: | KHONDAKAR | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S 80TH AVE STE 1630 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089237878 | ||||||||
| FaxNumber: | 7089237888 | ||||||||
| Practice Location | |||||||||
| Address1: | 12255 S 80TH AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089237878 | ||||||||
| FaxNumber: | 7089237888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 036098281 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036098281 | 05 | IL | MEDICAID |