Healthcare Provider Details

I. General information

NPI: 1063638682
Provider Name (Legal Business Name): MICHAEL T COURIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3969 4TH AVE SUITE 301
SAN DIEGO CA
92103-3165
US

IV. Provider business mailing address

3969 4TH AVE SUITE 301
SAN DIEGO CA
92103-3165
US

V. Phone/Fax

Practice location:
  • Phone: 619-291-6191
  • Fax: 619-291-0049
Mailing address:
  • Phone: 619-291-6191
  • Fax: 619-291-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA53265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: