Individual
OMAR F GHANDOUR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
7601 SOUTHCREST PKWY, SOUTHAVEN, MS 38671-4739
(662) 772-2130
(662) 772-2131
Mailing address
PO BOX 405827, ATLANTA, GA 30384-5827
Taxonomy
Speciality
Code
Description
License number
State
2085R0001X
Radiation Oncology Physician
Primary
22217
MS
2085R0001X
Radiation Oncology Physician
36779
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00127062
—
MS
05
—
148872001
—
AR
05
—
3876529
—
TN
01
—
4046696
BLUE CROSS BLUE SHIELD
TN
01
—
7160133
AETNA
—
01
—
99465
BLUE CROSS BLUE SHIELD
AR
Enumeration date
08/22/2005
Last updated
03/30/2018
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