Healthcare Provider Details

I. General information

NPI: 1609891415
Provider Name (Legal Business Name): NEIL M KHETERPAL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE SUITE 715
HACKENSACK NJ
07601-1997
US

IV. Provider business mailing address

452 OLD HOOK RD 2ND FLOOR
EMERSON NJ
07630-1381
US

V. Phone/Fax

Practice location:
  • Phone: 201-881-0721
  • Fax: 201-881-0725
Mailing address:
  • Phone: 201-666-3900
  • Fax: 201-261-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number270700
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number25MB08320000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier25MB08320000
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNJ MEDICAL LICENSE
# 2
Identifier03647014
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: