Provider Demographics
NPI:1346278066
Name:KOUDELLOU, ALEXIA T (MD)
Entity Type:Individual
Prefix:
First Name:ALEXIA
Middle Name:T
Last Name:KOUDELLOU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SIX FIELDSTONE COMMONS
Mailing Address - Street 2:SUITE D
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084
Mailing Address - Country:US
Mailing Address - Phone:860-871-6710
Mailing Address - Fax:860-896-4869
Practice Address - Street 1:SIX FIELDSTONE COMMONS
Practice Address - Street 2:SUITE D
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084
Practice Address - Country:US
Practice Address - Phone:860-871-6710
Practice Address - Fax:860-896-4869
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT044946207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH74009Medicare UPIN
NY9255TAMedicare ID - Type Unspecified