Provider Demographics
NPI:1760480578
Name:HALAKA, GAMAL L (PT)
Entity Type:Individual
Prefix:
First Name:GAMAL
Middle Name:L
Last Name:HALAKA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 SUNSET STRIP
Mailing Address - Street 2:P.O. BOX 47
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-1311
Mailing Address - Country:US
Mailing Address - Phone:973-584-1616
Mailing Address - Fax:973-584-5368
Practice Address - Street 1:79 SUNSET STRIP
Practice Address - Street 2:
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1311
Practice Address - Country:US
Practice Address - Phone:973-584-1616
Practice Address - Fax:973-584-5368
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00270600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ000716692Medicare ID - Type Unspecified