Healthcare Provider Details

I. General information

NPI: 1255323663
Provider Name (Legal Business Name): OMAR F GHANDOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4739
US

IV. Provider business mailing address

PO BOX 405827
ATLANTA GA
30384-5827
US

V. Phone/Fax

Practice location:
  • Phone: 662-772-2130
  • Fax: 662-772-2131
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number22217
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number36779
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: