Provider Demographics
NPI:1427012681
Name:HASSAN, MOHAMMAD R (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:R
Last Name:HASSAN
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:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:2000 W 21ST ST
Practice Address - Street 2:W7
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4087
Practice Address - Country:US
Practice Address - Phone:575-763-3666
Practice Address - Fax:575-762-3520
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3891207RC0000X
NM20030757207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153906603Medicaid
NM23371340Medicaid
NM348431307OtherMEDICARE
TXTXB123657OtherMEDICARE
NM23371340Medicaid
343504001Medicare PIN
TXTXB123657Medicare PIN
H72186Medicare UPIN