Healthcare Provider Details

I. General information

NPI: 1104886910
Provider Name (Legal Business Name): WISSAM E KHOURY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 E 22ND ST
CLEVELAND OH
44115
US

IV. Provider business mailing address

429 FRONT ST
BEREA OH
44017-1716
US

V. Phone/Fax

Practice location:
  • Phone: 216-367-9444
  • Fax: 216-453-0331
Mailing address:
  • Phone: 216-367-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36003289
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: