Provider Demographics
NPI:1306842059
Name:GHANDOUR, ELIAS CAMILLE (MD)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:CAMILLE
Last Name:GHANDOUR
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 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:STE 3 N
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2905
Mailing Address - Country:US
Mailing Address - Phone:443-444-3775
Mailing Address - Fax:443-444-4678
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:STE 3
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:443-444-3775
Practice Address - Fax:443-444-4678
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0035706207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD52322301OtherBLUE SHIELD
MD206901200Medicaid
MD52322301OtherBLUE SHIELD