Provider Demographics
NPI:1255694600
Name:GADDOR, MOATAZ M (MD)
Entity Type:Individual
Prefix:DR
First Name:MOATAZ
Middle Name:M
Last Name:GADDOR
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 1:222 S WOODS MILL RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3625
Mailing Address - Country:US
Mailing Address - Phone:314-205-6050
Mailing Address - Fax:314-434-5939
Practice Address - Street 1:222 S WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3625
Practice Address - Country:US
Practice Address - Phone:314-205-6050
Practice Address - Fax:314-434-5939
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012017419207R00000X
IL036153985207R00000X, 207RP1001X, 207RS0012X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255694600Medicaid