Provider Demographics
NPI:1619927373
Name:KHAMMAR, GEORGE SOUHEL (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:SOUHEL
Last Name:KHAMMAR
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 1:1017 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3915
Mailing Address - Country:US
Mailing Address - Phone:817-334-2800
Mailing Address - Fax:817-820-0094
Practice Address - Street 1:1017 12TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3915
Practice Address - Country:US
Practice Address - Phone:817-334-2800
Practice Address - Fax:817-820-0094
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4489207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1558264-02Medicaid
TX10008961OtherAMERIGROUP
TX1558264-01Medicaid
7462025OtherAETNA PROVIDER ID
TX8G2851OtherBCBS
G58671Medicare UPIN
TX1558264-02Medicaid
TX1558264-01Medicaid
TXP00024869Medicare PIN
TX8A0349Medicare PIN