Basic Information
| Provider Information | |||||||||
| NPI: | 1255694600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GADDOR | ||||||||
| FirstName: | MOATAZ | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 S WOODS MILL RD | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142056050 | ||||||||
| FaxNumber: | 3144345939 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 S WOODS MILL RD | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142056050 | ||||||||
| FaxNumber: | 3144345939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2012017419 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036153985 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 036153985 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | 036153985 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RC0200X | 036153985 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1255694600 | 05 | WI | MEDICAID |