Healthcare Provider Details

I. General information

NPI: 1619434586
Provider Name (Legal Business Name): IRTIZA HASAN MD, MSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST FL 4
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

655 W 8TH ST FL 4
JACKSONVILLE FL
32209-6511
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-6761
  • Fax: 904-244-4431
Mailing address:
  • Phone: 904-244-6761
  • Fax: 904-244-4431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME151670
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN28121
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: