Provider Demographics
NPI:1124665930
Name:TASSAWER, JAWAD
Entity type:Individual
Prefix:
First Name:JAWAD
Middle Name:
Last Name:TASSAWER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 FARMRANCH RD E
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-4023
Mailing Address - Country:US
Mailing Address - Phone:516-710-8356
Mailing Address - Fax:
Practice Address - Street 1:407 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-3951
Practice Address - Country:US
Practice Address - Phone:212-475-5760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist