Provider Demographics
NPI:1396727236
Name:KHOUDARY, RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
Last Name:KHOUDARY
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 1:190 S RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705-1149
Mailing Address - Country:US
Mailing Address - Phone:570-970-1400
Mailing Address - Fax:570-970-1403
Practice Address - Street 1:190 S RIVER ST
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1149
Practice Address - Country:US
Practice Address - Phone:570-970-1400
Practice Address - Fax:570-970-1403
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048279L207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014930060002Medicaid
PA100260Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAF84206Medicare UPIN