Provider Demographics
NPI:1477622884
Name:KOUTCHER, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:KOUTCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 HARRIS BUSHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HARRIS
Mailing Address - State:NY
Mailing Address - Zip Code:12742
Mailing Address - Country:US
Mailing Address - Phone:845-791-7828
Mailing Address - Fax:
Practice Address - Street 1:68 HARRIS BUSHVILLE RD
Practice Address - Street 2:
Practice Address - City:HARRIS
Practice Address - State:NY
Practice Address - Zip Code:12742
Practice Address - Country:US
Practice Address - Phone:845-791-7828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07301100207PE0004X
NY138528207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00382178Medicaid
NJ8747407Medicaid
NJ056869QJ2Medicare PIN
NJ056870Medicare PIN
NYA48384Medicare UPIN
NY00382178Medicaid