Provider Demographics
NPI:1790165785
Name:HASANUDDIN, HARRISON (DO)
Entity type:Individual
Prefix:
First Name:HARRISON
Middle Name:
Last Name:HASANUDDIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N GARFIELD AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1206
Mailing Address - Country:US
Mailing Address - Phone:626-763-1899
Mailing Address - Fax:626-547-4438
Practice Address - Street 1:420 N GARFIELD AVE STE 203
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1206
Practice Address - Country:US
Practice Address - Phone:626-763-1899
Practice Address - Fax:626-547-4438
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16309207QB0002X, 207QS1201X, 207Q00000X
CAOT016681207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine