Provider Demographics
NPI:1518586536
Name:KHODOROV, GREGG ILAN (MD, MBA)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:ILAN
Last Name:KHODOROV
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PATERSON ST APT 803
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-2142
Mailing Address - Country:US
Mailing Address - Phone:973-303-2674
Mailing Address - Fax:
Practice Address - Street 1:1015 WALNUT ST STE 620
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5005
Practice Address - Country:US
Practice Address - Phone:215-955-6864
Practice Address - Fax:215-955-2878
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program