Provider Demographics
NPI:1497863278
Name:HATHOUT, GASSER MAHGR (MD)
Entity Type:Individual
Prefix:MR
First Name:GASSER
Middle Name:MAHGR
Last Name:HATHOUT
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 1:1622 SAN GABRIEL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208
Mailing Address - Country:US
Mailing Address - Phone:818-242-7350
Mailing Address - Fax:818-242-7350
Practice Address - Street 1:14445 OLIVEVIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342
Practice Address - Country:US
Practice Address - Phone:818-364-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG662612085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C7662610Medicaid
CAG662610Medicare ID - Type Unspecified
CA00C7662610Medicaid