Provider Demographics
NPI:1073517462
Name:HANNA, MAMDOUH S (MD)
Entity Type:Individual
Prefix:
First Name:MAMDOUH
Middle Name:S
Last Name:HANNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-0464
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:29 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-4654
Practice Address - Country:US
Practice Address - Phone:201-858-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07574700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0039934Medicaid
I06992Medicare UPIN
NJ079444Medicare ID - Type Unspecified