Provider Demographics
NPI:1376676775
Name:KOUO, THERESA (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KOUO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-812-4083
Mailing Address - Fax:717-812-2244
Practice Address - Street 1:35 MONUMENT RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5074
Practice Address - Country:US
Practice Address - Phone:717-812-4083
Practice Address - Fax:717-812-2244
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00643462085D0003X
PAMD4605362085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1020900Medicaid
CAWA102090BMedicare PIN
CA0A1020900Medicaid