Provider Demographics
NPI:1275636433
Name:HASAN, SAFIUL (MD)
Entity Type:Individual
Prefix:
First Name:SAFIUL
Middle Name:
Last Name:HASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 HIGHLAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1975
Mailing Address - Country:US
Mailing Address - Phone:248-682-4900
Mailing Address - Fax:248-682-4909
Practice Address - Street 1:4000 HIGHLAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2167
Practice Address - Country:US
Practice Address - Phone:248-682-4900
Practice Address - Fax:248-682-4909
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISH036123174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1781235Medicaid
MIP09560001Medicare ID - Type Unspecified
MI1781235Medicaid