Provider Demographics
NPI:1316567134
Name:PHILLIP G KOULTOURIDES, O.D. P.C.
Entity Type:Organization
Organization Name:PHILLIP G KOULTOURIDES, O.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KOULTOURIDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-670-6589
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
Mailing Address - Country:US
Mailing Address - Phone:219-670-6589
Mailing Address - Fax:
Practice Address - Street 1:210 INDIANAPOLIS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375
Practice Address - Country:US
Practice Address - Phone:219-322-3819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty