Provider Demographics
NPI:1508031824
Name:HASSAN, CHANDRA (MD,)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:
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 1:1801 W TAYLOR ST STE 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4795
Mailing Address - Country:US
Mailing Address - Phone:312-355-1493
Mailing Address - Fax:312-355-1987
Practice Address - Street 1:1801 W TAYLOR ST STE 3F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-355-1493
Practice Address - Fax:312-355-1987
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432412208600000X
CAA115017208600000X
OH35.093595208600000X
IL036139682208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2963468Medicaid