Provider Demographics
NPI:1700464062
Name:ELLAITHY, HATEM ABDALLAH (MD)
Entity Type:Individual
Prefix:
First Name:HATEM
Middle Name:ABDALLAH
Last Name:ELLAITHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HATEM
Other - Middle Name:OMAR
Other - Last Name:ABDALLAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-5001
Mailing Address - Country:US
Mailing Address - Phone:475-319-5207
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:857-282-3083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2888624207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine