Healthcare Provider Details

I. General information

NPI: 1871054346
Provider Name (Legal Business Name): ANTOINE KENNETH KHOURY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8536 WILSHIRE BLVD STE 102
BEVERLY HILLS CA
90211-3154
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 310-248-7501
  • Fax:
Mailing address:
  • Phone: 734-718-2716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.074915
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125.074915
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20A20942
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: