Provider Demographics
NPI:1376834515
Name:DR. ESSAM KHEDR, DPM, LLC
Entity Type:Organization
Organization Name:DR. ESSAM KHEDR, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRY PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ESSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHEDR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:978-249-1295
Mailing Address - Street 1:80 MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331-3559
Mailing Address - Country:US
Mailing Address - Phone:978-249-1295
Mailing Address - Fax:978-249-5669
Practice Address - Street 1:80 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-3559
Practice Address - Country:US
Practice Address - Phone:978-249-1295
Practice Address - Fax:978-249-5669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2353213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty