Basic Information
| Provider Information | |||||||||
| NPI: | 1609891415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHETERPAL | ||||||||
| FirstName: | NEIL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 452 OLD HOOK RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076301381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016663900 | ||||||||
| FaxNumber: | 2012610505 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 PROSPECT AVE | ||||||||
| Address2: | SUITE 715 | ||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018810721 | ||||||||
| FaxNumber: | 2018810725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 270700 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 25MB08320000 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 25MB08320000 | 01 | NJ | NJ MEDICAL LICENSE | OTHER | 03647014 | 05 | NY | MEDICAID |