Healthcare Provider Details

I. General information

NPI: 1932556842
Provider Name (Legal Business Name): KHADIJATUL KOBRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 PACIFIC AVE
ATLANTIC CITY NJ
08401-6713
US

IV. Provider business mailing address

42 E LAUREL RD 3100
STRATFORD NJ
08084-1354
US

V. Phone/Fax

Practice location:
  • Phone: 609-441-8146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MB10483200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: