1679933998 NPI number — TAREK R KHATER

Table of content: (NPI 1679933998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679933998 NPI number — TAREK R KHATER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAREK R KHATER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1679933998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 672
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10028-0044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-960-0821
Provider Business Mailing Address Fax Number:
646-952-2004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2814 31ST ST
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-960-0821
Provider Business Practice Location Address Fax Number:
713-575-3865
Provider Enumeration Date:
02/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KHATER
Authorized Official First Name:
TAREK
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWENER
Authorized Official Telephone Number:
917-960-0821

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0208X , with the licence number: 300724 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3517284 . This is a "DBA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 128919 . This is a "MEDICAL LICENSE NYC MRC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00093517 . This is a "CCI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 175911 . This is a "ARDMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 91504840501 . This is a "AMA (ME#)" identifier . This identifiers is of the category "OTHER".




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