Provider Demographics
NPI:1073611877
Name:KOUMAS, PETER CONSTANTINE (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:CONSTANTINE
Last Name:KOUMAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SUGAR CAMP CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1962
Mailing Address - Country:US
Mailing Address - Phone:937-222-3937
Mailing Address - Fax:937-223-5416
Practice Address - Street 1:105 SUGAR CAMP CIR
Practice Address - Street 2:STE 200
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1962
Practice Address - Country:US
Practice Address - Phone:937-222-3937
Practice Address - Fax:937-223-5416
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003248K207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0552469Medicaid
OH1031790001Medicare NSC
OHKO4061332Medicare ID - Type Unspecified
OH0552469Medicaid
OHH174020Medicare PIN