Provider Demographics
NPI:1013962430
Name:KHOORY, WISSAM J (MD)
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:J
Last Name:KHOORY
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 1:20 HOPE AVE
Mailing Address - Street 2:SUITE. G03
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2721
Mailing Address - Country:US
Mailing Address - Phone:781-893-4490
Mailing Address - Fax:
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:SUITE G03
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2721
Practice Address - Country:US
Practice Address - Phone:781-893-4490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine