Healthcare Provider Details

I. General information

NPI: 1134771702
Provider Name (Legal Business Name): MOEEZ HASSAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 22ND ST
SIOUX FALLS SD
57105-1521
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-312-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD-49533
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351044256
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMD-49533
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier4351044256
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: