Healthcare Provider Details

I. General information

NPI: 1093344012
Provider Name (Legal Business Name): AMANDA JO KHOURI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8680 MONROE CT STE 200
RANCHO CUCAMONGA CA
91730-9104
US

IV. Provider business mailing address

400 W MINERAL KING AVE
VISALIA CA
93291-6237
US

V. Phone/Fax

Practice location:
  • Phone: 909-987-0899
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA190188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: