Provider Demographics
NPI:1619358181
Name:KADDOURAH, OSAMA KHALED ALI (MD)
Entity Type:Individual
Prefix:
First Name:OSAMA
Middle Name:KHALED ALI
Last Name:KADDOURAH
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 1:1640 WOODBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-8501
Mailing Address - Country:US
Mailing Address - Phone:410-912-5640
Mailing Address - Fax:
Practice Address - Street 1:1640 WOODBROOKE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-8501
Practice Address - Country:US
Practice Address - Phone:410-912-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2021-08-31
Deactivation Date:2016-01-20
Deactivation Code:
Reactivation Date:2016-02-08
Provider Licenses
StateLicense IDTaxonomies
MO2015017267207R00000X, 207RG0100X
390200000X
MDD0092318207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program