Provider Demographics
NPI:1063505055
Name:KOUKOULAS, ELAINE TINA (MD)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:TINA
Last Name:KOUKOULAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6501 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6819
Mailing Address - Country:US
Mailing Address - Phone:410-938-3000
Mailing Address - Fax:410-938-5131
Practice Address - Street 1:6535 N CHARLES ST
Practice Address - Street 2:SUITE 300
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-5826
Practice Address - Country:US
Practice Address - Phone:410-938-5252
Practice Address - Fax:410-928-5250
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00591242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5116023-00Medicaid
MD132676Y52Medicare PIN
MDH70774Medicare UPIN