Provider Demographics
NPI:1720456049
Name:KHATER, TAREK R (MD,)
Entity type:Individual
Prefix:
First Name:TAREK
Middle Name:R
Last Name:KHATER
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:229 E 85TH ST
Mailing Address - Street 2:672
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-9600
Mailing Address - Country:US
Mailing Address - Phone:917-960-0821
Mailing Address - Fax:646-952-2004
Practice Address - Street 1:229 E 85TH ST
Practice Address - Street 2:672
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-9600
Practice Address - Country:US
Practice Address - Phone:917-960-0821
Practice Address - Fax:646-952-2004
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2010966 PTAL208D00000X
NCCCI: 00093517246XS1301X
MDARDMS: 1769112471S1302X
NY128919208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY128919OtherNYC MRC
NY3517284OtherDBA