Healthcare Provider Details

I. General information

NPI: 1396727236
Provider Name (Legal Business Name): RAYMOND KHOUDARY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 S RIVER ST
PLAINS PA
18705-1149
US

IV. Provider business mailing address

190 S RIVER ST
PLAINS PA
18705-1149
US

V. Phone/Fax

Practice location:
  • Phone: 570-970-1400
  • Fax: 570-970-1403
Mailing address:
  • Phone: 570-970-1400
  • Fax: 570-970-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD048279L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: