Healthcare Provider Details

I. General information

NPI: 1366954091
Provider Name (Legal Business Name): AGHNATIOUS A HANNA AWADALLA HANNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 PROSPECT AVE
HACKENSACK NJ
07601-2625
US

IV. Provider business mailing address

316 PROSPECT AVE
HACKENSACK NJ
07601-2625
US

V. Phone/Fax

Practice location:
  • Phone: 201-923-0454
  • Fax: 973-827-6636
Mailing address:
  • Phone: 201-923-0454
  • Fax: 973-827-6636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number426745
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier0-426-745-6
Identifier TypeOTHER
Identifier State
Identifier IssuerECFMG

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: