Healthcare Provider Details

I. General information

NPI: 1396499141
Provider Name (Legal Business Name): FAWAD HASSAN VIQAR PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SMITH HAVEN MALL STE 107
LAKE GROVE NY
11755-1219
US

IV. Provider business mailing address

120 HARRISON DR
CENTERPORT NY
11721-1306
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-8053
  • Fax: 631-444-4267
Mailing address:
  • Phone: 718-309-5815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number024506
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number024506
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: