Provider Demographics
NPI:1154736452
Name:HASSAN, SUMMER MUSTAFA (DO)
Entity type:Individual
Prefix:
First Name:SUMMER
Middle Name:MUSTAFA
Last Name:HASSAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 FRANKLIN AVE
Mailing Address - Street 2:SUITE #110
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3592
Mailing Address - Country:US
Mailing Address - Phone:309-268-3502
Mailing Address - Fax:309-268-3713
Practice Address - Street 1:1300 FRANKLIN AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3592
Practice Address - Country:US
Practice Address - Phone:309-268-3502
Practice Address - Fax:309-268-3713
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125065755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine