Provider Demographics
NPI:1154702157
Name:GHABBOUR, MARC (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:GHABBOUR
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 1:455 PHILIP BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8768
Mailing Address - Country:US
Mailing Address - Phone:800-611-1811
Mailing Address - Fax:
Practice Address - Street 1:455 PHILIP BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:800-611-1811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLTRN21395207R00000X
GA081035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty