Provider Demographics
NPI:1790733210
Name:ELBANNA, KHALED OMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:KHALED
Middle Name:OMAR
Last Name:ELBANNA
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 1:2543 STEINWAY STREET
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3503
Mailing Address - Country:US
Mailing Address - Phone:718-706-8060
Mailing Address - Fax:718-707-8650
Practice Address - Street 1:2543 STEINWAY STREET
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103
Practice Address - Country:US
Practice Address - Phone:718-706-8060
Practice Address - Fax:718-706-8650
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-02-01
Deactivation Date:2020-12-09
Deactivation Code:
Reactivation Date:2021-02-01
Provider Licenses
StateLicense IDTaxonomies
NY224801-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4C7293OtherHEALTHNET
NYKE05269N10Medicare PIN
NYH93578Medicare UPIN
NY07505GMedicare PIN