Provider Demographics
NPI:1205908761
Name:HASAN, SHABIH U (MD)
Entity type:Individual
Prefix:
First Name:SHABIH
Middle Name:U
Last Name: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 1:722 GRANT ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4532
Mailing Address - Country:US
Mailing Address - Phone:703-787-7638
Mailing Address - Fax:703-787-7654
Practice Address - Street 1:722 GRANT ST
Practice Address - Street 2:SUITE F
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4532
Practice Address - Country:US
Practice Address - Phone:703-787-7638
Practice Address - Fax:703-787-7654
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056360174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA07115873Medicaid
VA07115873Medicaid
VA490924Medicare PIN