Provider Demographics
NPI:1295847986
Name:KOULTOURIDES, PHILLIP GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:GEORGE
Last Name:KOULTOURIDES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9140 DRAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9066
Mailing Address - Country:US
Mailing Address - Phone:219-365-8069
Mailing Address - Fax:
Practice Address - Street 1:2400 MORTHLAND DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-465-2788
Practice Address - Fax:219-465-2785
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist