Basic Information
| Provider Information | |||||||||
| NPI: | 1124384797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHADDR | ||||||||
| FirstName: | MANSOUR | ||||||||
| MiddleName: | ELTAHER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 428 S DURBIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073374284 | ||||||||
| FaxNumber: | 3072243436 | ||||||||
| Practice Location | |||||||||
| Address1: | 1453A DEWAR DR | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073822466 | ||||||||
| FaxNumber: | 8883950359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2012 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 12748A | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 12748A | WY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.