Provider Demographics
NPI:1871848531
Name:KHADER, TAREQ (MD)
Entity Type:Individual
Prefix:
First Name:TAREQ
Middle Name:
Last Name:KHADER
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 1:11190 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-5729
Mailing Address - Country:US
Mailing Address - Phone:239-330-2933
Mailing Address - Fax:
Practice Address - Street 1:11190 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-5729
Practice Address - Country:US
Practice Address - Phone:239-330-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.020825207R00000X, 390200000X
FLME123496207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program