Provider Demographics
NPI:1972715381
Name:GHOURY, ABDULLAH KHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDULLAH
Middle Name:KHAN
Last Name:GHOURY
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 1:16393 EL REVINO DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5840
Mailing Address - Country:US
Mailing Address - Phone:347-200-6968
Mailing Address - Fax:
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
Practice Address - Country:US
Practice Address - Phone:909-881-4520
Practice Address - Fax:909-881-4526
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96810208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00472046OtherRR MEDICARE
CA00A968100OtherBCBS OF CA
CA00A968100Medicaid
CAFG0308963OtherDEA
CAP00472046Medicare PIN
CAFG0308963OtherDEA