Provider Demographics
NPI:1003999301
Name:KHOURY, FARID ELIE (OD)
Entity Type:Individual
Prefix:DR
First Name:FARID
Middle Name:ELIE
Last Name:KHOURY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5644
Mailing Address - Country:US
Mailing Address - Phone:505-979-0894
Mailing Address - Fax:505-726-2871
Practice Address - Street 1:1500 S 2ND ST STE 5
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5898
Practice Address - Country:US
Practice Address - Phone:505-979-0894
Practice Address - Fax:505-726-2871
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM536152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44840OtherDAVIS VISION
NM52032019Medicaid
NM25676OtherSPECTERA