Provider Demographics
NPI:1821190935
Name:KHOURY, NIDAL Y (MD)
Entity Type:Individual
Prefix:
First Name:NIDAL
Middle Name:Y
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 1:336 78TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209
Mailing Address - Country:US
Mailing Address - Phone:718-745-6693
Mailing Address - Fax:718-748-4097
Practice Address - Street 1:336 78TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209
Practice Address - Country:US
Practice Address - Phone:718-745-6693
Practice Address - Fax:718-748-4097
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126536207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00400784Medicaid
NY06A711Medicare ID - Type Unspecified
NY00400784Medicaid