Healthcare Provider Details

I. General information

NPI: 1689092728
Provider Name (Legal Business Name): FUAD FREDRIC ELKHOURY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2014
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 15TH ST STE 1200
SANTA MONICA CA
90404-1147
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-7700
  • Fax: 424-529-6289
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA138701
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberA138701
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: