Basic Information
| Provider Information | |||||||||
| NPI: | 1427012681 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HASSAN | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W 21ST ST | ||||||||
| Address2: | W7 | ||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881014087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757633666 | ||||||||
| FaxNumber: | 5757623520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | L3891 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 20030757 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 153906603 | 05 | TX | MEDICAID | 23371340 | 05 | NM | MEDICAID | 348431307 | 01 | NM | MEDICARE | OTHER | TXB123657 | 01 | TX | MEDICARE | OTHER |