Healthcare Provider Details

I. General information

NPI: 1679955421
Provider Name (Legal Business Name): MR. HAZEM OTHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2015
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 RICHARDSON DR
RICHARDSON TX
75080-4648
US

IV. Provider business mailing address

7605 PADDOCK TRL
SACHSE TX
75048-6699
US

V. Phone/Fax

Practice location:
  • Phone: 972-759-2180
  • Fax:
Mailing address:
  • Phone: 540-247-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1254716
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: