Provider Demographics
NPI:1437197837
Name:HASSAN, KHALED A (MD)
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:A
Last Name:HASSAN
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 1:71 HOOVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-1705
Mailing Address - Country:US
Mailing Address - Phone:201-248-6080
Mailing Address - Fax:
Practice Address - Street 1:1300 MAIN AVENUE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011
Practice Address - Country:US
Practice Address - Phone:973-942-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06977000207R00000X, 207VG0400X, 207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0082716Medicaid
NJ082716Medicaid
NJ0082716Medicaid
NJ082716Medicaid