Healthcare Provider Details

I. General information

NPI: 1295064343
Provider Name (Legal Business Name): WISSAM KHOURY DPM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2009
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: WISSAM KHOURY
Title or Position: OWNER
Credential: DPM
Phone: 216-921-3668