Provider Demographics
NPI:1780013953
Name:KHAWAJA, ANITA (BS)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:KHAWAJA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 FRELINGHUYSEN AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07114-1349
Mailing Address - Country:US
Mailing Address - Phone:973-799-0508
Mailing Address - Fax:
Practice Address - Street 1:687 FRELINGHUYSEN AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114-1334
Practice Address - Country:US
Practice Address - Phone:973-799-0508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000172261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0062821Medicaid
NJ7466200Medicaid