Provider Demographics
NPI:1568483691
Name:KOURY, THEOPHILE G (MD)
Entity Type:Individual
Prefix:
First Name:THEOPHILE
Middle Name:G
Last Name:KOURY
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 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:510-879-9100
Practice Address - Street 1:1601 YGNACIO VALLEY RD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3122
Practice Address - Country:US
Practice Address - Phone:925-939-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83451207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G834510Medicaid
CA00G834510Medicare PIN
CAG46803Medicare UPIN