Provider Demographics
NPI:1114934718
Name:ALEXIA T. KOUDELLOU MD, PC
Entity Type:Organization
Organization Name:ALEXIA T. KOUDELLOU MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIA
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:KOUDELLOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-932-8767
Mailing Address - Street 1:3275 STEINWAY ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4046
Mailing Address - Country:US
Mailing Address - Phone:718-932-8767
Mailing Address - Fax:718-932-8768
Practice Address - Street 1:3275 STEINWAY ST
Practice Address - Street 2:SUITE 206
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4046
Practice Address - Country:US
Practice Address - Phone:718-932-8767
Practice Address - Fax:718-932-8768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230323207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty