Provider Demographics
NPI:1972790020
Name:AL-KHATIB, TAREQ (MD)
Entity Type:Individual
Prefix:MR
First Name:TAREQ
Middle Name:
Last Name:AL-KHATIB
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 1:2852 TAMIAMI TRL
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5125
Mailing Address - Country:US
Mailing Address - Phone:941-625-4442
Mailing Address - Fax:941-625-9797
Practice Address - Street 1:2852 TAMIAMI TRL
Practice Address - Street 2:SUITE 5
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5125
Practice Address - Country:US
Practice Address - Phone:941-625-4442
Practice Address - Fax:941-625-9797
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054967208600000X
FLME0054121208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049600600Medicaid
FL07707Medicare PIN
FLB17996Medicare UPIN