Basic Information
| Provider Information | |||||||||
| NPI: | 1538144498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELZOOBI | ||||||||
| FirstName: | KHALDOUN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3214 NORTH ILLINOIS ST | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182330742 | ||||||||
| FaxNumber: | 6182339784 | ||||||||
| Practice Location | |||||||||
| Address1: | 3214 NORTH ILLINOIS ST | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182330742 | ||||||||
| FaxNumber: | 6182339784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 112176 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 036090591 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036090591 | 05 | IL | MEDICAID | 08222610 | 01 | BC FL | OTHER | 17723 | 01 | GHP | OTHER | 112518 | 01 | BC MO | OTHER | 1207324 | 01 | UHC | OTHER |