Provider Demographics
NPI:1720393077
Name:KHOURY, LAITH (MD)
Entity Type:Individual
Prefix:
First Name:LAITH
Middle Name:
Last Name:KHOURY
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 1:5838 SIX FORKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-3885
Mailing Address - Country:US
Mailing Address - Phone:919-785-3400
Mailing Address - Fax:919-783-7778
Practice Address - Street 1:5838 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3885
Practice Address - Country:US
Practice Address - Phone:919-785-3400
Practice Address - Fax:919-783-7778
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYR2513207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100254130Medicaid