Provider Demographics
NPI:1669468864
Name:HASSANEIN, HOSSAM M (MD)
Entity type:Individual
Prefix:
First Name:HOSSAM
Middle Name:M
Last Name:HASSANEIN
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 1:437-439 NW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8731
Mailing Address - Country:US
Mailing Address - Phone:561-972-4180
Mailing Address - Fax:561-972-4180
Practice Address - Street 1:437-439 NW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8731
Practice Address - Country:US
Practice Address - Phone:561-972-4180
Practice Address - Fax:561-972-4180
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68679207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379604300Medicaid
FL379604300Medicaid
FL28313VMedicare ID - Type Unspecified