Provider Demographics
NPI:1366639262
Name:ANGELOS KOUTSONIKOLIS MD PA
Entity Type:Organization
Organization Name:ANGELOS KOUTSONIKOLIS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELOS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUTSONIKOLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:561-733-3546
Mailing Address - Street 1:10075 JOG RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-3535
Mailing Address - Country:US
Mailing Address - Phone:561-733-3546
Mailing Address - Fax:561-733-3547
Practice Address - Street 1:10075 JOG RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3535
Practice Address - Country:US
Practice Address - Phone:561-733-3546
Practice Address - Fax:561-733-3547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63824207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K7612Medicare PIN