Healthcare Provider Details

I. General information

NPI: 1285862185
Provider Name (Legal Business Name): HASSAN ALI HASSAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 WHITEHALL DR
ST AUGUSTINE FL
32086-5266
US

IV. Provider business mailing address

7015 A C SKINNER PKWY SUITE 1
JACKSONVILLE FL
32256-6932
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-4500
  • Fax: 904-825-3672
Mailing address:
  • Phone: 904-363-2113
  • Fax: 904-363-2606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME124175
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: