Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | DC13575 | CA |
Y | 213ER0200X | Radiology | DC13575 | CA |
NPI | 1245350396 |
---|---|
Provider Name | Dr. Andre Elie Khoury |
First Address | Sherman Oaks, CA 91403-5470 |
Second Address | Sherman Oaks, CA 91403-5470 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
54220DC0135750 | BLUE SHIELD OF CALIFORNIA (01) | CA |
PIN 0004399228 | AETNA (01) | CA |