Basic Information
| Provider Information | |||||||||
| NPI: | 1376656488 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSABBAL | ||||||||
| FirstName: | ELTAYEB | ||||||||
| MiddleName: | IDRIS | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 191 | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197230191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 IRVING AVE. | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083022123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564516600 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 09/01/2011 | ||||||||
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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 | 2080N0001X | 25MA08089700 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | D08906700 | 01 | NJ | CDS | OTHER | BM9856646 | 01 | DEA | OTHER |