Provider Demographics
NPI:1619434586
Name:HASAN, MD. IRTIZA (MD, MSC)
Entity Type:Individual
Prefix:DR
First Name:MD. IRTIZA
Middle Name:
Last Name:HASAN
Suffix:
Gender:M
Credentials:MD, MSC
Other - Prefix:
Other - First Name:IRTIZA
Other - Middle Name:
Other - Last Name:HASAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MSC
Mailing Address - Street 1:655 W 8TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-244-6761
Mailing Address - Fax:904-244-4431
Practice Address - Street 1:655 W 8TH ST FL 4
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-6761
Practice Address - Fax:904-244-4431
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN28121390200000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program