Provider Demographics
NPI:1326133646
Name:KOUSOUROU, HARITON (MD)
Entity Type:Individual
Prefix:
First Name:HARITON
Middle Name:
Last Name:KOUSOUROU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:452 HEALTH PARKWAY
Mailing Address - Street 2:SUITE F
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079
Mailing Address - Country:US
Mailing Address - Phone:269-655-3080
Mailing Address - Fax:269-655-0761
Practice Address - Street 1:45 ROUTE 25A
Practice Address - Street 2:SUITE C
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-1389
Practice Address - Country:US
Practice Address - Phone:631-821-2626
Practice Address - Fax:631-744-1627
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY156800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01026700Medicaid
82D621Medicare ID - Type Unspecified
NY01026700Medicaid