Healthcare Provider Details

I. General information

NPI: 1194456103
Provider Name (Legal Business Name): MOHAMMED MOIZUL HASSAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 STATE ST # 340
LA PORTE IN
46350-3112
US

IV. Provider business mailing address

1331 STATE ST # 340
LA PORTE IN
46350-3112
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.080257
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number036.175601
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01098602A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: