Provider Demographics
NPI:1275704611
Name:KHOURY, ANTOINE E (MD)
Entity Type:Individual
Prefix:
First Name:ANTOINE
Middle Name:E
Last Name:KHOURY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51342
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-5642
Mailing Address - Country:US
Mailing Address - Phone:714-509-3910
Mailing Address - Fax:714-509-3917
Practice Address - Street 1:505 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4568
Practice Address - Country:US
Practice Address - Phone:714-509-3919
Practice Address - Fax:714-509-3917
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC531872088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0085140OtherMEDICAID GRP
CAW14887OtherMEDICARE GROUP