Healthcare Provider Details

I. General information

NPI: 1124681705
Provider Name (Legal Business Name): DR. OMAR HASAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST # N408
JACKSON MS
39216-4500
US

IV. Provider business mailing address

4639 KIRKLEY DR
JACKSON MS
39206-3301
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-2828
  • Fax:
Mailing address:
  • Phone: 210-965-7501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME160204
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberT-5146
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: