Basic Information
| Provider Information | |||||||||
| NPI: | 1699719138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHANDOUR | ||||||||
| FirstName: | ELIAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4515 MARSHA SHARP FWY | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794072520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0674472238 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Practice Location | |||||||||
| Address1: | 3814 22ND PL | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794101118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067954500 | ||||||||
| FaxNumber: | 8067954792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | H4930 | TX | N | Other Service Providers | Specialist | 207RG0100X | H4930 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 113568304 | 05 | TX | MEDICAID |