Healthcare Provider Details

I. General information

NPI: 1013228246
Provider Name (Legal Business Name): MARIAM WASSEF HANNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 UTAH AVE STE 200
EL SEGUNDO CA
90245-4817
US

IV. Provider business mailing address

PO BOX 100374
GAINESVILLE FL
32610-0374
US

V. Phone/Fax

Practice location:
  • Phone: 281-766-0959
  • Fax:
Mailing address:
  • Phone: 352-265-0291
  • Fax: 352-265-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME125175
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: