Basic Information
| Provider Information | |||||||||
| NPI: | 1437155017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHODOR | ||||||||
| FirstName: | YOUSSEF | ||||||||
| MiddleName: | KHALIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KHODOR | ||||||||
| OtherFirstName: | YOUSSEF | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2066 | ||||||||
| Address2: | |||||||||
| City: | LECANTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344602066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525630931 | ||||||||
| FaxNumber: | 3525630935 | ||||||||
| Practice Location | |||||||||
| Address1: | 1907 HIGHWAY 44 W | ||||||||
| Address2: | |||||||||
| City: | INVERNESS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344533801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523442273 | ||||||||
| FaxNumber: | 3523442204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS8274 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 51756 | 01 | FL | BCBS | OTHER | 264799100 | 05 | FL | MEDICAID |