Healthcare Provider Details

I. General information

NPI: 1912216938
Provider Name (Legal Business Name): HAYTHUM OSAMA TAYEB MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2010
Last Update Date: 11/29/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BRADHURST AVE STE 3850S
HAWTHORNE NY
10532-2140
US

IV. Provider business mailing address

19 BRADHURST AVE # 3850S
HAWTHORNE NY
10532-2140
US

V. Phone/Fax

Practice location:
  • Phone: 914-909-9018
  • Fax:
Mailing address:
  • Phone: 914-909-9018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number320038
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number320038
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number247487
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number245772
License Number StateMA
# 7
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number320038
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: