Provider Demographics
NPI:1831251446
Name:KHAN, HASIBUL HASSAN (MD)
Entity type:Individual
Prefix:
First Name:HASIBUL
Middle Name:HASSAN
Last Name:KHAN
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 1:3404 N LECANTO HWY SUITE C
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-4830
Mailing Address - Country:US
Mailing Address - Phone:352-746-0600
Mailing Address - Fax:352-746-3838
Practice Address - Street 1:213 S PINE AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4830
Practice Address - Country:US
Practice Address - Phone:352-560-3000
Practice Address - Fax:352-419-6513
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001124800Medicaid
FLAO990ZMedicare Oscar/Certification
FL001124800Medicaid
MIP22450009Medicare PIN