Provider Demographics
NPI:1346564028
Name:KHAITOV, DIANA (PA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KHAITOV
Suffix:
Gender:F
Credentials:PA
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 717
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-0717
Mailing Address - Country:US
Mailing Address - Phone:800-345-0064
Mailing Address - Fax:973-251-1109
Practice Address - Street 1:1 CLARA MAASS DR
Practice Address - Street 2:CLARA MAASS MEDICAL CENTER
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3550
Practice Address - Country:US
Practice Address - Phone:973-450-2000
Practice Address - Fax:973-251-1109
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00183400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant