Provider Demographics
NPI:1043566318
Name:HASSAN, SURA (OD)
Entity Type:Individual
Prefix:DR
First Name:SURA
Middle Name:
Last Name:HASSAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:248-581-5976
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:4717 ST. ANTOINE
Practice Address - Street 2:KRESGE EYE INSTITUTE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1423
Practice Address - Country:US
Practice Address - Phone:313-577-8900
Practice Address - Fax:313-577-0700
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32140007Medicare PIN