Provider Demographics
NPI:1427511732
Name:HASSAN, MOIZ (DPM)
Entity type:Individual
Prefix:
First Name:MOIZ
Middle Name:
Last Name:HASSAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 N EAST RIVER RD UNIT B2
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1251
Mailing Address - Country:US
Mailing Address - Phone:847-338-1958
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-8118
Practice Address - Country:US
Practice Address - Phone:815-776-7265
Practice Address - Fax:815-777-2560
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL016.005969213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program