Provider Demographics
NPI:1376656488
Name:MASSABBAL, ELTAYEB IDRIS (M D)
Entity Type:Individual
Prefix:
First Name:ELTAYEB
Middle Name:IDRIS
Last Name:MASSABBAL
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19723-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4000
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:333 IRVING AVE.
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2123
Practice Address - Country:US
Practice Address - Phone:856-451-6600
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4447932080N0001X
NJ25MA080897002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD08906700OtherCDS
BM9856646OtherDEA