Provider Demographics
NPI:1730823659
Name:BANGA, KHALID OSMAN JR
Entity type:Individual
Prefix:
First Name:KHALID
Middle Name:OSMAN
Last Name:BANGA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 N BROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-4301
Mailing Address - Country:US
Mailing Address - Phone:908-344-6291
Mailing Address - Fax:
Practice Address - Street 1:570 N BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-4301
Practice Address - Country:US
Practice Address - Phone:908-344-6291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00396000156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician