Provider Demographics
NPI:1124384797
Name:KHADDR, MANSOUR ELTAHER (MD)
Entity Type:Individual
Prefix:
First Name:MANSOUR
Middle Name:ELTAHER
Last Name:KHADDR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1204 HILLTOP DR STE 106
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5861
Mailing Address - Country:US
Mailing Address - Phone:307-522-5555
Mailing Address - Fax:888-819-5155
Practice Address - Street 1:1204 HILLTOP DR STE 106
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5861
Practice Address - Country:US
Practice Address - Phone:307-522-5555
Practice Address - Fax:888-819-5155
Is Sole Proprietor?:No
Enumeration Date:2012-04-08
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12748A207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology