Provider Demographics
NPI:1194974162
Name:KASSAB, MARIA FERNANDA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:FERNANDA
Last Name:KASSAB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 E 149TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5504
Mailing Address - Country:US
Mailing Address - Phone:718-579-5000
Mailing Address - Fax:
Practice Address - Street 1:435 57TH ST
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2119
Practice Address - Country:US
Practice Address - Phone:201-295-1456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280291207RG0100X
NJ25MA11463400207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0955663Medicaid