Provider Demographics
NPI:1740546266
Name:HANNA, MADOUNA GAMAL (DO)
Entity type:Individual
Prefix:
First Name:MADOUNA
Middle Name:GAMAL
Last Name:HANNA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30 BERGEN ST RM 1205
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:972-972-0037
Mailing Address - Fax:973-972-0743
Practice Address - Street 1:230 E RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-967-4000
Practice Address - Fax:201-967-4117
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09675100208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0638234Medicaid