Healthcare Provider Details

I. General information

NPI: 1609134808
Provider Name (Legal Business Name): ANTHONY B KHABUT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2177 VICTORY BLVD
STATEN ISLAND NY
10314-6603
US

IV. Provider business mailing address

185 GUYON AVE
STATEN ISLAND NY
10306-3947
US

V. Phone/Fax

Practice location:
  • Phone: 718-370-3730
  • Fax: 718-698-9412
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number279050
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number279050
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: