Provider Demographics
NPI:1629276803
Name:GHANDOUR, ABDULRAOUF G (MD)
Entity Type:Individual
Prefix:
First Name:ABDULRAOUF
Middle Name:G
Last Name:GHANDOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:188 WORCESTER PROVIDENCE TPKE
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:MA
Practice Address - Zip Code:01590-1908
Practice Address - Country:US
Practice Address - Phone:508-865-3650
Practice Address - Fax:508-865-3822
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA251361207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095423AMedicaid