Provider Demographics
NPI:1801854450
Name:HASSANEIN, TAREK I (MD)
Entity Type:Individual
Prefix:PROF
First Name:TAREK
Middle Name:I
Last Name:HASSANEIN
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:PO BOX 181770
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92178-1770
Mailing Address - Country:US
Mailing Address - Phone:619-964-9649
Mailing Address - Fax:
Practice Address - Street 1:131 ORANGE AVE STE 101
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1408
Practice Address - Country:US
Practice Address - Phone:619-522-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54452207RI0008X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A544520Medicaid
CAF96609Medicare UPIN
CAWA54452AMedicare ID - Type Unspecified