Provider Demographics
NPI:1780657148
Name:RIZVI, HASAN AIJAZ (MD)
Entity type:Individual
Prefix:DR
First Name:HASAN
Middle Name:AIJAZ
Last Name:RIZVI
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 1:180 E MAIN ST
Mailing Address - Street 2:STE 5
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8427
Mailing Address - Country:US
Mailing Address - Phone:631-645-2842
Mailing Address - Fax:866-252-3902
Practice Address - Street 1:180 E MAIN ST
Practice Address - Street 2:SUITE #5
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8427
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-675-2001
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2019-07-09
Deactivation Date:2019-06-28
Deactivation Code:
Reactivation Date:2019-07-03
Provider Licenses
StateLicense IDTaxonomies
NY158747207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00869003Medicaid
NY00869003Medicaid
NYA62014Medicare UPIN