1205917952 NPI number — MITRA ASSADI-KHANSARI MD

Table of content: MITRA ASSADI-KHANSARI MD (NPI 1205917952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205917952 NPI number — MITRA ASSADI-KHANSARI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ASSADI-KHANSARI
Provider First Name:
MITRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205917952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HYGEIA DR
Provider Second Line Business Mailing Address:
STE 1420
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-623-3017
Provider Business Mailing Address Fax Number:
302-266-9962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HYGEIA DR
Provider Second Line Business Practice Location Address:
STE 1420
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-623-3017
Provider Business Practice Location Address Fax Number:
302-266-9962
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0402X , with the licence number:  C1-0013230 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: C1-0013230 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0064051000 . This is a "AMERIHEALTH/KEYSTONE/IBC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7712201 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1010223 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0342325 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1883383 . This is a "UNITED HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: HORIZON NJ HEALTH . This is a "1169152" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 18376 . This is a "AMERIHEALTH/PPO PABS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 018376 . This is a "PA BS HIGHMARK" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3K5933 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P2182793 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 20495 . This is a "UNIVERSITY HEALTH PLAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: CA0000306 . This is a "AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3009843 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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