Provider Demographics
NPI:1578978995
Name:KHOUDARI, GEORGE (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:KHOUDARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10050 SW INNOVATION WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2117
Mailing Address - Country:US
Mailing Address - Phone:772-223-5945
Mailing Address - Fax:772-345-5365
Practice Address - Street 1:10050 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2117
Practice Address - Country:US
Practice Address - Phone:772-223-5945
Practice Address - Fax:772-345-5365
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.131927207R00000X
FLME168343207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine