Provider Demographics
NPI:1487036265
Name:HATHIDARA, MAUSAMINBEN YUNUSALI (MD)
Entity Type:Individual
Prefix:
First Name:MAUSAMINBEN
Middle Name:YUNUSALI
Last Name:HATHIDARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NE 53RD ST APT 2709
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-1862
Mailing Address - Country:US
Mailing Address - Phone:832-781-9433
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD
Practice Address - Street 2:SUITE 2040
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-4113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK313822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology