Provider Demographics
NPI:1174551824
Name:KHADDASH, SALEH (MD)
Entity type:Individual
Prefix:
First Name:SALEH
Middle Name:
Last Name:KHADDASH
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 1:241 RATZER RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-5440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:969 PAULISON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-3629
Practice Address - Country:US
Practice Address - Phone:973-546-3355
Practice Address - Fax:973-546-8501
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA58895174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6068308Medicaid
NJF52050Medicare UPIN
NJ6068308Medicaid