Provider Demographics
NPI:1144242686
Name:KOUVELIOTES, PETER J (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:KOUVELIOTES
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 1:1001 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2579
Mailing Address - Country:US
Mailing Address - Phone:732-462-3302
Mailing Address - Fax:732-780-6213
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:MEDICAL ARTS BUILDING
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2537
Practice Address - Country:US
Practice Address - Phone:732-462-3302
Practice Address - Fax:732-780-6213
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA072051002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8571708Medicaid
NJ047921Medicare PIN
NJ047921DCMMedicare PIN
NJ8571708Medicaid