Provider Demographics
NPI:1619027364
Name:MASSOUMI, HATEF (MD)
Entity Type:Individual
Prefix:DR
First Name:HATEF
Middle Name:
Last Name:MASSOUMI
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 1:1250 WATERS PL
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2720
Mailing Address - Country:US
Mailing Address - Phone:718-239-0115
Mailing Address - Fax:718-239-0446
Practice Address - Street 1:1250 WATERS PL
Practice Address - Street 2:SUITE 1201
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2720
Practice Address - Country:US
Practice Address - Phone:718-239-0115
Practice Address - Fax:718-239-0446
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221502207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02194838Medicaid
NY004AJ1Medicare ID - Type Unspecified
NY02194838Medicaid