Provider Demographics
NPI:1699182717
Name:ALZIADAT, MOAYYAD RADI BARHAM (MBBS)
Entity Type:Individual
Prefix:
First Name:MOAYYAD
Middle Name:RADI BARHAM
Last Name:ALZIADAT
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 MAIN ST
Mailing Address - Street 2:INTERNAL MEDICINE DEPARTMENT-5TH FLOOR
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2621
Mailing Address - Country:US
Mailing Address - Phone:973-754-2000
Mailing Address - Fax:
Practice Address - Street 1:245 FLEMINGSBURG RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1015
Practice Address - Country:US
Practice Address - Phone:606-780-5500
Practice Address - Fax:606-783-7281
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10422300207R00000X
KY53642207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100677340Medicaid
KY53642OtherKY MEDICAL LICENSE