Provider Demographics
NPI:1770987315
Name:KADDOURA, MAHMOUD A
Entity type:Individual
Prefix:DR
First Name:MAHMOUD
Middle Name:A
Last Name:KADDOURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 OLD CORNWALLIS RD
Mailing Address - Street 2:STE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-1869
Mailing Address - Country:US
Mailing Address - Phone:919-932-5700
Mailing Address - Fax:919-933-6881
Practice Address - Street 1:433 TURK ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-3329
Practice Address - Country:US
Practice Address - Phone:415-928-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC273671363LA2200X, 363LG0600X
NC102018363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology