Healthcare Provider Details

I. General information

NPI: 1295947141
Provider Name (Legal Business Name): RAYMOND KHOUDARY MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
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 Code207KA0200X
TaxonomyAllergy Physician
License NumberMD048279L
License Number StatePA

VIII. Authorized Official

Name: MRS. DEBBIE BROWN
Title or Position: BILLING OFFICE
Credential:
Phone: 570-970-1400