Provider Demographics
NPI:1235186453
Name:KOUYOUMDJIAN, PAULINE (DO)
Entity Type:Individual
Prefix:DR
First Name:PAULINE
Middle Name:
Last Name:KOUYOUMDJIAN
Suffix:
Gender:F
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:PO BOX 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-6335
Mailing Address - Country:US
Mailing Address - Phone:215-639-1281
Mailing Address - Fax:215-639-3016
Practice Address - Street 1:2807 BRISTOL PIKE
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-5362
Practice Address - Country:US
Practice Address - Phone:215-639-1281
Practice Address - Fax:215-639-3016
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS011958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA300064321OtherKEYSTONE MERCY
PA1012149350002Medicaid
PA2310985000OtherKEYSTONE IBC
PA37957OS11958OtherHEALTH PARTNERS
PA1635838OtherHIGHMARK BLUE SHIELD
PA1956179OtherAETNA HMO
PA37957OS11958OtherHEALTH PARTNERS
PA1635838OtherHIGHMARK BLUE SHIELD
PA082987Medicare ID - Type Unspecified