Healthcare Provider Details

I. General information

NPI: 1629276803
Provider Name (Legal Business Name): ABDULRAOUF G. GHANDOUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 WORCESTER PROVIDENCE TPKE
SUTTON MA
01590-1908
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-865-3650
  • Fax: 508-865-3822
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number251361
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number251361
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: