Provider Demographics
NPI:1013081322
Name:GHUMRAWI, BADR KHALIL (MD)
Entity Type:Individual
Prefix:
First Name:BADR
Middle Name:KHALIL
Last Name:GHUMRAWI
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 1:43 SAN SIMEON
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-7951
Mailing Address - Country:US
Mailing Address - Phone:949-495-5161
Mailing Address - Fax:
Practice Address - Street 1:43 SAN SIMEON
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7951
Practice Address - Country:US
Practice Address - Phone:949-495-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC518602086S0129X, 208G00000X, 2086S0129X, 208G00000X
OH350368362086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4132029OtherAETNA
OH0231538Medicaid
100430OtherKAISER
000000129043OtherANTHEM
27174OtherNATIONWIDE
71479OtherQUALCHOICE
71479OtherQUALCHOICE
OH0231538Medicaid