Provider Demographics
NPI:1467441006
Name:KOUTNIK, DEBRA L (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:KOUTNIK
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 1:2620 E BARNETT RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8344
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-2558
Practice Address - Street 1:628 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1710
Practice Address - Country:US
Practice Address - Phone:541-201-4930
Practice Address - Fax:541-201-4931
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD190832080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR107650Medicare PIN
OKF83898Medicare UPIN