Provider Demographics
NPI:1104886910
Name:KHOURY, WISSAM E (DPM)
Entity type:Individual
Prefix:
First Name:WISSAM
Middle Name:E
Last Name:KHOURY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1716
Mailing Address - Country:US
Mailing Address - Phone:216-367-9444
Mailing Address - Fax:
Practice Address - Street 1:2351 E 22ND ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115
Practice Address - Country:US
Practice Address - Phone:216-367-9444
Practice Address - Fax:216-453-0331
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003289213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2487116Medicaid
OH2487116Medicaid