Provider Demographics
NPI:1417030412
Name:KHOURY, MONA
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:KHOURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1685 B GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510
Mailing Address - Country:US
Mailing Address - Phone:516-378-1280
Mailing Address - Fax:516-378-0086
Practice Address - Street 1:1407 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-998-6684
Practice Address - Fax:718-998-0513
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004635-1213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02088342Medicaid
NY5970160001Medicare NSC
NYT93222Medicare UPIN
NY02088342Medicaid