Basic Information
| Provider Information | |||||||||
| NPI: | 1649276965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOURI | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 903 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761023421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775353 | ||||||||
| FaxNumber: | 8178775357 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761023421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775353 | ||||||||
| FaxNumber: | 8178775357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | P3183 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QA0505X | A63589 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A635890 | 05 | CA | MEDICAID |