Provider Demographics
NPI:1770951758
Name:HASAN KHONDKER MEDICAL PC
Entity type:Organization
Organization Name:HASAN KHONDKER MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REP
Authorized Official - Prefix:
Authorized Official - First Name:HASAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:KHONDKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-727-5112
Mailing Address - Street 1:758 HARRISON AVE
Mailing Address - Street 2:EASTERN SUFFOLK NEPHROLOGY
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2744
Mailing Address - Country:US
Mailing Address - Phone:631-727-5112
Mailing Address - Fax:631-727-9061
Practice Address - Street 1:758 HARRISON AVE
Practice Address - Street 2:758 HARRISON AVENUE
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2744
Practice Address - Country:US
Practice Address - Phone:631-727-5112
Practice Address - Fax:631-727-9061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100132150Medicare PIN