Provider Demographics
NPI:1124027172
Name:KOUYOUMDJI, PAUL R (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:KOUYOUMDJI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504290
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:856-935-3582
Mailing Address - Fax:856-935-4382
Practice Address - Street 1:4 BY PASS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079-2053
Practice Address - Country:US
Practice Address - Phone:856-935-3582
Practice Address - Fax:856-935-4382
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA64453208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
099433Medicare PIN
G44233Medicare UPIN