Healthcare Provider Details

I. General information

NPI: 1639599673
Provider Name (Legal Business Name): KAVEH HAJIFATHALIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BERGEN ST STE H-446
NEWARK NJ
07103-2496
US

IV. Provider business mailing address

242 W 53RD ST APT 46A
NEW YORK NY
10019-7894
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-9814
  • Fax:
Mailing address:
  • Phone: 646-962-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number25MA11205700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number290254
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: