Healthcare Provider Details

I. General information

NPI: 1679933998
Provider Name (Legal Business Name): TAREK R KHATER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 08/08/2020
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 31ST ST SUITE 501
ASTORIA NY
11102
US

IV. Provider business mailing address

PO BOX 672
NEW YORK NY
10028-0044
US

V. Phone/Fax

Practice location:
  • Phone: 917-960-0821
  • Fax: 713-575-3865
Mailing address:
  • Phone: 917-960-0821
  • Fax: 646-952-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number300724
License Number StateNY

VIII. Authorized Official

Name: TAREK R KHATER
Title or Position: OWENER
Credential: MD
Phone: 917-960-0821