Provider Demographics
NPI:1114925922
Name:KHADOUR, LUNA I (MD)
Entity type:Individual
Prefix:
First Name:LUNA
Middle Name:I
Last Name:KHADOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12276 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8628
Mailing Address - Country:US
Mailing Address - Phone:904-268-5561
Mailing Address - Fax:904-268-5506
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8628
Practice Address - Country:US
Practice Address - Phone:904-268-5561
Practice Address - Fax:904-268-5506
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0083314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0083314OtherFL LICENSE
FL03243OtherBLUE CROSS BLUE SHIELD
FL000984800Medicaid
FLH53540Medicare UPIN
FL000984800Medicaid
FL03243YMedicare PIN
FLRR P00709647Medicare PIN