Provider Demographics
NPI:1285695015
Name:HATEFI, HOMAYOON (MD)
Entity type:Individual
Prefix:DR
First Name:HOMAYOON
Middle Name:
Last Name:HATEFI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HOMAYOON
Other - Middle Name:
Other - Last Name:HATEFI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PA
Mailing Address - Street 1:145 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450
Mailing Address - Country:US
Mailing Address - Phone:201-445-7776
Mailing Address - Fax:201-445-4209
Practice Address - Street 1:145 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-445-7776
Practice Address - Fax:201-445-4209
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137050207R00000X
NJMA32611207RG0100X
DC9325207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4727100Medicaid
NJ427773Medicare ID - Type Unspecified
C54242Medicare UPIN