Provider Demographics
NPI:1831490184
Name:GATEWAY COMPREHENSIVE MEDICAL GROUP
Entity type:Organization
Organization Name:GATEWAY COMPREHENSIVE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSANEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-990-1698
Mailing Address - Street 1:PO BOX 181770
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92178-1770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:995 GATEWAY CENTER WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4500
Practice Address - Country:US
Practice Address - Phone:619-264-1934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54452208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty