Provider Demographics
NPI:1437479052
Name:HASAN, SAMIRA M (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMIRA
Middle Name:M
Last Name:HASAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MILES CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-4047
Mailing Address - Country:US
Mailing Address - Phone:207-563-4252
Mailing Address - Fax:207-563-4275
Practice Address - Street 1:24 MILES CENTER WAY
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4047
Practice Address - Country:US
Practice Address - Phone:207-563-4252
Practice Address - Fax:207-563-4275
Is Sole Proprietor?:No
Enumeration Date:2010-06-05
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT011661208600000X
MO2012007469208600000X
MEDO2516208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MOP01063532OtherRR MCR
MO1437479052Medicaid
MO431560263OtherTRICARE