Provider Demographics
NPI:1679933998
Name:TAREK R KHATER
Entity Type:Organization
Organization Name:TAREK R KHATER
Other - Org Name:TAREK R KHATER MEDICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:R
Authorized Official - Last Name:KHATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-960-0821
Mailing Address - Street 1:PO BOX 672
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0044
Mailing Address - Country:US
Mailing Address - Phone:917-960-0821
Mailing Address - Fax:646-952-2004
Practice Address - Street 1:2814 31ST ST
Practice Address - Street 2:SUITE 501
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102
Practice Address - Country:US
Practice Address - Phone:917-960-0821
Practice Address - Fax:713-575-3865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X
NY300724261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3517284OtherDBA
NY128919OtherMEDICAL LICENSE NYC MRC
00093517OtherCCI
175911OtherARDMS
91504840501OtherAMA (ME#)