Provider Demographics
NPI:1881888030
Name:KHOURY, LISA D (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:KHOURY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 BATH RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2637
Mailing Address - Country:US
Mailing Address - Phone:207-442-0350
Mailing Address - Fax:207-442-0355
Practice Address - Street 1:430 BATH RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2637
Practice Address - Country:US
Practice Address - Phone:207-442-0350
Practice Address - Fax:207-442-0355
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD19391207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000523603Medicare PIN