Healthcare Provider Details

I. General information

NPI: 1720456049
Provider Name (Legal Business Name): TAREK R KHATER M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 08/08/2020
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 E 85TH ST 672
NEW YORK NY
10028-9600
US

IV. Provider business mailing address

229 E 85TH ST 672
NEW YORK NY
10028-9600
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2010966 PTAL
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License NumberCCI: 00093517
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License NumberARDMS: 176911
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number128919
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: