Provider Demographics
NPI:1124072780
Name:HASAN, OMAR (MD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:HASAN
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 1:220 GERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3184
Mailing Address - Country:US
Mailing Address - Phone:860-830-6459
Mailing Address - Fax:
Practice Address - Street 1:1620 TREMONT ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-1613
Practice Address - Country:US
Practice Address - Phone:617-732-7063
Practice Address - Fax:617-732-7072
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038009207R00000X
MA230890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH15567Medicare UPIN