Provider Demographics
NPI:1558356402
Name:ABU-HASAN, MUTASIM N (MD)
Entity Type:Individual
Prefix:
First Name:MUTASIM
Middle Name:N
Last Name:ABU-HASAN
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 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-273-8379
Mailing Address - Fax:352-392-4450
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-8379
Practice Address - Fax:352-392-4450
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA334182080P0201X, 2080P0214X
KS04-332022080P0214X
FLME1079862080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002981400Medicaid
IA0212985Medicaid
IA17554OtherWELLMARK BCBS
IA0212985Medicaid
FL002981400Medicaid
IA370016529Medicare PIN
IA17554Medicare PIN