Provider Demographics
NPI:1457434169
Name:TAREQ AL-KHATIB
Entity Type:Organization
Organization Name:TAREQ AL-KHATIB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:TAREQ
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-KHATIB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-625-4442
Mailing Address - Street 1:2852 TAMIAMI TR
Mailing Address - Street 2:STE 5
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952
Mailing Address - Country:US
Mailing Address - Phone:941-625-4442
Mailing Address - Fax:941-625-9797
Practice Address - Street 1:2852 TAMIAMI TR
Practice Address - Street 2:STE 5
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952
Practice Address - Country:US
Practice Address - Phone:941-625-4442
Practice Address - Fax:941-625-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054121208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
07707Medicare ID - Type Unspecified
B17996Medicare UPIN