Healthcare Provider Details

I. General information

NPI: 1265091128
Provider Name (Legal Business Name): HASAN FARID HASAN OTHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FOUNDERS LN
JACKSONVILLE IL
62650-3919
US

IV. Provider business mailing address

15 FOUNDERS LN
JACKSONVILLE IL
62650-3919
US

V. Phone/Fax

Practice location:
  • Phone: 217-243-0300
  • Fax: 217-245-6775
Mailing address:
  • Phone: 217-243-0300
  • Fax: 217-245-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036160282
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: