Healthcare Provider Details

I. General information

NPI: 1275704611
Provider Name (Legal Business Name): ANTOINE E KHOURY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST STE 100
ORANGE CA
92868-4568
US

IV. Provider business mailing address

PO BOX 51342
LOS ANGELES CA
90051-5642
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-3919
  • Fax: 714-509-3917
Mailing address:
  • Phone: 714-509-3910
  • Fax: 714-509-3917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberC53187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: