Provider Demographics
NPI:1396800744
Name:HASSUR, MICHAEL J (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HASSUR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3300
Practice Address - Fax:253-596-3678
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001363152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2013969Medicaid
WA2013969Medicaid
WAGAB19088Medicare PIN
WAGAB19089Medicare PIN
WAG8872368Medicare PIN
WAGAB19087Medicare PIN
WAT43620Medicare UPIN
WAG001050892Medicare PIN
WAGAB23462Medicare PIN