Healthcare Provider Details

I. General information

NPI: 1043566318
Provider Name (Legal Business Name): SURA HASSAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4717 ST. ANTOINE KRESGE EYE INSTITUTE
DETROIT MI
48201-1423
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400-CREDENTIALING
TROY MI
48083-1138
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-8900
  • Fax: 313-577-0700
Mailing address:
  • Phone: 248-581-5976
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004721
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: