Healthcare Provider Details

I. General information

NPI: 1720440068
Provider Name (Legal Business Name): SARA KHODOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 GATEWAY DR
MELBOURNE FL
32901-2607
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-312-3491
  • Fax: 321-952-6946
Mailing address:
  • Phone: 321-312-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME136509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: