Provider Demographics
NPI:1477653467
Name:HASAN, MIRZA SHAHZAD (MD)
Entity Type:Individual
Prefix:
First Name:MIRZA
Middle Name:SHAHZAD
Last Name:HASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M
Other - Middle Name:SHAHZAD
Other - Last Name:HASAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:999 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1715
Mailing Address - Country:US
Mailing Address - Phone:419-893-5591
Mailing Address - Fax:419-893-0162
Practice Address - Street 1:999 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1715
Practice Address - Country:US
Practice Address - Phone:419-893-5591
Practice Address - Fax:419-893-0162
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-27855208600000X
OH35.098760208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100332720CMedicaid
OH0072146Medicaid
OHH127590OtherMEDICARE PTAN
KS100332720BMedicaid
KS100332720CMedicaid
KS003768038Medicare PIN