Provider Demographics
NPI:1245418201
Name:HAAS, SALLY JASMINE (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JASMINE
Last Name:HAAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:JASMINE
Other - Last Name:AHMED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1201 W LA VETA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4203
Mailing Address - Country:US
Mailing Address - Phone:714-509-3096
Mailing Address - Fax:714-509-7800
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4203
Practice Address - Country:US
Practice Address - Phone:714-509-3096
Practice Address - Fax:714-509-7800
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4408062080N0001X
TXP00592080N0001X
AZ379882080N0001X
CAA832142080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ331284Medicaid
AZ331284Medicaid