=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063638682
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL T COURIS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 03/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3969 4TH AVE SUITE 301
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-3165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-291-6191
-----------------------------------------------------
Fax | 619-291-0049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3969 4TH AVE SUITE 301
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-3165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-291-6191
-----------------------------------------------------
Fax | 619-291-0049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | A53265
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------