Provider Demographics
NPI:1548394414
Name:GHORAB, KHALED MUSTAFA (MD)
Entity Type:Individual
Prefix:DR
First Name:KHALED
Middle Name:MUSTAFA
Last Name:GHORAB
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 1:700 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4719
Mailing Address - Country:US
Mailing Address - Phone:337-238-6161
Mailing Address - Fax:337-238-0085
Practice Address - Street 1:700 S 6TH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4719
Practice Address - Country:US
Practice Address - Phone:337-238-6161
Practice Address - Fax:337-238-0085
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202557208600000X
DEC7-0003294208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA202557OtherLA LIC#