Provider Demographics
NPI:1639499718
Name:KOUCHOUK, AMR
Entity Type:Individual
Prefix:
First Name:AMR
Middle Name:
Last Name:KOUCHOUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8506
Mailing Address - Country:US
Mailing Address - Phone:714-399-0678
Mailing Address - Fax:714-276-6489
Practice Address - Street 1:22525 MAPLE AVE
Practice Address - Street 2:SUITE, 100
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2700
Practice Address - Country:US
Practice Address - Phone:310-803-9633
Practice Address - Fax:310-803-9634
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA137407207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology