Basic Information
| Provider Information | |||||||||
| NPI: | 1144661653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WADIE ALKHOURI MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 S. GRAND AVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917414286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263351919 | ||||||||
| FaxNumber: | 6263351911 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 S. GRAND AVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917414286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263351919 | ||||||||
| FaxNumber: | 6263351911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2013 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | ALKHOURI | ||||||||
| AuthorizedOfficialFirstName: | WADIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6263351919 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | C51885 | CA | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 1568556652 | 01 | CA | TYPE 1 NPI | OTHER | 000518850 | 05 | CA | MEDICAID |