Provider Demographics
NPI:1740722669
Name:HASSAN, HUMAIRA (OD,)
Entity type:Individual
Prefix:
First Name:HUMAIRA
Middle Name:
Last Name:HASSAN
Suffix:
Gender:F
Credentials:OD,
Other - Prefix:
Other - First Name:HUMAIRA
Other - Middle Name:
Other - Last Name:FAREED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1104 N HIGHWAY 377 STE 200
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-9124
Mailing Address - Country:US
Mailing Address - Phone:817-491-2018
Mailing Address - Fax:
Practice Address - Street 1:1104 N HIGHWAY 377 STE 200
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-9124
Practice Address - Country:US
Practice Address - Phone:817-491-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9118T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist