Provider Demographics
NPI:1265091128
Name:OTHMAN, HASAN FARID HASAN (MD)
Entity type:Individual
Prefix:
First Name:HASAN
Middle Name:FARID HASAN
Last Name:OTHMAN
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 1:15 FOUNDERS LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3919
Mailing Address - Country:US
Mailing Address - Phone:217-243-0300
Mailing Address - Fax:217-245-6775
Practice Address - Street 1:15 FOUNDERS LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3919
Practice Address - Country:US
Practice Address - Phone:217-243-0300
Practice Address - Fax:217-245-6775
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036160282208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036160282OtherIL MD LICENSE