Provider Demographics
NPI:1770574626
Name:GHATTAS, MAGED L (MD)
Entity type:Individual
Prefix:DR
First Name:MAGED
Middle Name:L
Last Name:GHATTAS
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 1:901 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2537
Mailing Address - Country:US
Mailing Address - Phone:732-336-1806
Mailing Address - Fax:732-333-8178
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2537
Practice Address - Country:US
Practice Address - Phone:732-336-1806
Practice Address - Fax:732-333-8178
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08212000207L00000X, 207LP2900X, 207LH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0205281Medicaid
NJ0205281Medicaid
NJ125785ZDSMMedicare PIN