Provider Demographics
NPI:1720440068
Name:KHODOR, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:KHODOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-574-9188
Mailing Address - Fax:321-952-6946
Practice Address - Street 1:1223 GATEWAY DR STE 2E
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-574-9188
Practice Address - Fax:321-952-6946
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME136509207RI0011X
390200000X
MI4301119104207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118273000Medicaid
FLQZ098OtherMEDICARE HF