Provider Demographics
NPI:1558318030
Name:AL-KHOURI, HAISAM (MD)
Entity Type:Individual
Prefix:
First Name:HAISAM
Middle Name:
Last Name:AL-KHOURI
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 1:2316 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-2406
Mailing Address - Country:US
Mailing Address - Phone:405-525-3330
Mailing Address - Fax:405-525-3360
Practice Address - Street 1:2316 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-2406
Practice Address - Country:US
Practice Address - Phone:405-525-3330
Practice Address - Fax:405-525-3360
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK184172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100223830Medicaid
OK300522071Medicare PIN
OK100223830Medicaid