Provider Demographics
NPI:1336142272
Name:KOURI, GREGORY ALLAN (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLAN
Last Name:KOURI
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:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-0819
Mailing Address - Country:US
Mailing Address - Phone:605-665-9638
Mailing Address - Fax:605-665-0526
Practice Address - Street 1:415 W 3RD ST
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-4201
Practice Address - Country:US
Practice Address - Phone:605-665-9638
Practice Address - Fax:605-665-0526
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD521152W00000X
NE1065152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36-3050195-07Medicaid
NENA1114002OtherNE MEDICARE PTAN NORFOLK, NE
NE22055OtherNE BLUE SHIELD
SD0004557OtherSD WELLMARK BLUE SHIELD
SD36-3050195-06Medicaid
521OtherDAKOTACARE
SD9200084Medicaid
NE22055OtherNE BLUE SHIELD
NE36-3050195-07Medicaid
NENA1114002Medicare PIN
SD4557Medicare ID - Type UnspecifiedSD MEDICARE PROVIDER ID