Basic Information
Provider Information | |||||||||
NPI: | 1972694941 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HAITHAM R. DIB M.D. LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 436 CHRIS GAUPP DR | ||||||||
Address2: | SUITE 204 | ||||||||
City: | GALLOWAY | ||||||||
State: | NJ | ||||||||
PostalCode: | 082054487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6096520100 | ||||||||
FaxNumber: | 6096527616 | ||||||||
Practice Location | |||||||||
Address1: | 436 CHRIS GAUPP DR | ||||||||
Address2: | SUITE 204 | ||||||||
City: | GALLOWAY | ||||||||
State: | NJ | ||||||||
PostalCode: | 082054487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6096520100 | ||||||||
FaxNumber: | 6096527616 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 04/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DIB | ||||||||
AuthorizedOfficialFirstName: | HAITHAM | ||||||||
AuthorizedOfficialMiddleName: | RIAD | ||||||||
AuthorizedOfficialTitleorPosition: | DOCTOR/OWNER | ||||||||
AuthorizedOfficialTelephone: | 6096520100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.