Provider Demographics
NPI:1295858371
Name:A&K KOUKLAKIS OD P.C.
Entity Type:Organization
Organization Name:A&K KOUKLAKIS OD P.C.
Other - Org Name:VISION QUEST EYE CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:HARIDIMOS
Authorized Official - Last Name:KOUKLAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-756-1700
Mailing Address - Street 1:521 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1910
Mailing Address - Country:US
Mailing Address - Phone:219-882-9397
Mailing Address - Fax:219-882-9649
Practice Address - Street 1:521 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1910
Practice Address - Country:US
Practice Address - Phone:219-882-9397
Practice Address - Fax:219-882-9649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100215150CMedicaid
IN708660Medicare ID - Type Unspecified