Provider Demographics
NPI:1295847978
Name:KOUTSONIKOLIS, ANGELOS
Entity Type:Individual
Prefix:
First Name:ANGELOS
Middle Name:
Last Name:KOUTSONIKOLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10075 S JOG RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-3532
Mailing Address - Country:US
Mailing Address - Phone:561-733-3546
Mailing Address - Fax:561-733-3547
Practice Address - Street 1:10075 S JOG RD STE 100
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3532
Practice Address - Country:US
Practice Address - Phone:561-733-3546
Practice Address - Fax:561-733-3547
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63824207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272058200Medicaid
K7612Medicare PIN
FL28552AMedicare ID - Type Unspecified