Provider Demographics
NPI:1144807694
Name:HASSAN, KHALED (MD)
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:HASSAN
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 1:1601 W 40TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6069
Mailing Address - Country:US
Mailing Address - Phone:870-541-6010
Mailing Address - Fax:870-541-6009
Practice Address - Street 1:1601 W 40TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6069
Practice Address - Country:US
Practice Address - Phone:870-541-6010
Practice Address - Fax:870-541-6009
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE15868207P00000X
390200000X
ARE15898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program