Basic Information
Provider Information | |||||||||
NPI: | 1235579293 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ABOUL-NASR | ||||||||
FirstName: | KHALID | ||||||||
MiddleName: | GAMAL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1255 W WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | TEMPE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852811210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026855211 | ||||||||
FaxNumber: | 6026855325 | ||||||||
Practice Location | |||||||||
Address1: | 350 N WILMOT RD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026855211 | ||||||||
FaxNumber: | 6026855325 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2013 | ||||||||
LastUpdateDate: | 08/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 53563 | AZ | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZC0500X | 53563 | AZ | N |   | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
ID Information
ID | Type | State | Issuer | Description | 458765 | 05 | AZ |   | MEDICAID | 53563 | 01 | AZ | ARIZONA MEDICAL LICENSE | OTHER |