MEDICARE: LEILA KHADDOUR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	4301105339	MI
2	207RX0202X	Medical Oncology Physician	4301105339	MI
3	207RX0202X	Medical Oncology Physician	MC-0480	ID

General Provider Information

NPI Number	:	1750797486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEILA KHADDOUR MD

Provider Business Mailing Address
First Line	:	3340 E GOLDSTONE DR
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-1026
Country	:	US
Telephone Number	:	208-367-5170
Fax Number	:	208-367-5180

Provider Business Practice Location Address
First Line	:	3123 MEDICAL DR
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-6972
Country	:	US
Telephone Number	:	208-367-3131
Fax Number	:	208-367-4817

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	07/21/2022

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