Healthcare Provider Details

I. General information

NPI: 1770494569
Provider Name (Legal Business Name): KHIZER YASEEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BALDWIN RD
HEMPSTEAD NY
11550-6844
US

IV. Provider business mailing address

19 WALLIS AVE
JERSEY CITY NJ
07306-6415
US

V. Phone/Fax

Practice location:
  • Phone: 617-586-5632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP145318
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: