Provider Demographics
NPI:1598744658
Name:GHANDOUR, HASSAN A (MD)
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:A
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 1:1460 G ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4112
Mailing Address - Country:US
Mailing Address - Phone:541-726-4406
Mailing Address - Fax:541-744-6063
Practice Address - Street 1:1460 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4112
Practice Address - Country:US
Practice Address - Phone:541-726-4406
Practice Address - Fax:541-744-6063
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR135843Medicare PIN
F28180Medicare UPIN
OR078279Medicaid