Provider Demographics
NPI:1659802361
Name:HARSOUNI, IMAD OMAR
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:OMAR
Last Name:HARSOUNI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 RIVER RD APT 403
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-6369
Mailing Address - Country:US
Mailing Address - Phone:917-864-2930
Mailing Address - Fax:
Practice Address - Street 1:705B ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-2032
Practice Address - Country:US
Practice Address - Phone:201-861-1851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10960700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine