Basic Information
| Provider Information | |||||||||
| NPI: | 1710328604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHADDAM | ||||||||
| FirstName: | SINAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 | ||||||||
| Address2: | CENTRAL CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453104 | ||||||||
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| Practice Location | |||||||||
| Address1: | 234 GOODMAN STREET | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135587581 | ||||||||
| FaxNumber: | 5135840468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2013 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301102623 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35 128788 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.