Provider Demographics
NPI:1104212265
Name:GHOPRIAL, MAGED (MD)
Entity Type:Individual
Prefix:
First Name:MAGED
Middle Name:
Last Name:GHOPRIAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 44TH AVENUE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8126
Mailing Address - Country:US
Mailing Address - Phone:309-779-4050
Mailing Address - Fax:309-779-4057
Practice Address - Street 1:5401 44TH AVENUE DR STE 101
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-8126
Practice Address - Country:US
Practice Address - Phone:309-779-4050
Practice Address - Fax:309-779-4057
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036148480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine