Provider Demographics
NPI:1093799496
Name:KOURY, MICHAEL JOHN (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KOURY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20211 PATIO DR
Mailing Address - Street 2:#205
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4338
Mailing Address - Country:US
Mailing Address - Phone:510-537-3991
Mailing Address - Fax:510-537-7997
Practice Address - Street 1:20211 PATIO DRIVE
Practice Address - Street 2:STE 205
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546
Practice Address - Country:US
Practice Address - Phone:510-537-3991
Practice Address - Fax:510-537-7997
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ16603ZOtherMEDICARE GROUP PTAN
CAZZZ16603ZOtherMEDICARE GROUP PTAN