Healthcare Provider Details

I. General information

NPI: 1861584773
Provider Name (Legal Business Name): AMIRA KHATIB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 WILLIAMSON ST
ELIZABETH NJ
07202-3625
US

IV. Provider business mailing address

15 GALLOWAE
WATCHUNG NJ
07069-6413
US

V. Phone/Fax

Practice location:
  • Phone: 908-994-5760
  • Fax:
Mailing address:
  • Phone: 908-222-0503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA30372
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: