Provider Demographics
NPI:1174767644
Name:HASNIE, OMAR ABDUL QAYYUM (DO)
Entity type:Individual
Prefix:MR
First Name:OMAR
Middle Name:ABDUL QAYYUM
Last Name:HASNIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10351 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1904
Mailing Address - Country:US
Mailing Address - Phone:260-203-9600
Mailing Address - Fax:260-739-6167
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-203-9600
Practice Address - Fax:260-739-6167
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02004000A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201112190Medicaid
IN000000816146OtherANTHEM BCBS
IN692190009Medicare PIN