Provider Demographics
NPI:1205917952
Name:ASSADI-KHANSARI, MITRA (MD)
Entity type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:ASSADI-KHANSARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HYGEIA DR
Mailing Address - Street 2:STE 1420
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:302-623-3017
Mailing Address - Fax:302-266-9962
Practice Address - Street 1:200 HYGEIA DR
Practice Address - Street 2:STE 1420
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2049
Practice Address - Country:US
Practice Address - Phone:302-623-3017
Practice Address - Fax:302-266-9962
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00132302084N0402X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0064051000OtherAMERIHEALTH/KEYSTONE/IBC
NJ7712201Medicaid
NJ1010223OtherHORIZON NJ HEALTH
NJ0342325OtherCIGNA
NJ1883383OtherUNITED HEALTH
NJHORIZON NJ HEALTHOther1169152
NJ18376OtherAMERIHEALTH/PPO PABS
NJ018376OtherPA BS HIGHMARK
NJ3K5933OtherHEALTHNET
NJP2182793OtherOXFORD
NJ20495OtherUNIVERSITY HEALTH PLAN
NJCA0000306OtherAMERICHOICE
NJ3009843OtherAETNA
NJ20495OtherUNIVERSITY HEALTH PLAN
NJ018376OtherPA BS HIGHMARK
NJ3K5933OtherHEALTHNET
NJG21424Medicare UPIN