Provider Demographics
NPI:1306838719
Name:KHOURY, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
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 1:1711 27TH ST
Mailing Address - Street 2:BRAUNLIN BLDG, SUITE 306
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2638
Mailing Address - Country:US
Mailing Address - Phone:740-353-8661
Mailing Address - Fax:740-354-3254
Practice Address - Street 1:1711 27TH ST
Practice Address - Street 2:BRAUNLIN BLDG, SUITE 306
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2638
Practice Address - Country:US
Practice Address - Phone:740-353-8661
Practice Address - Fax:740-354-3254
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-5158K208600000X
OH35-651582086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64938434Medicaid
KY6493843400Medicaid
OH0968690Medicaid
OHA78264Medicare UPIN
OH0968690Medicaid