Provider Demographics
NPI:1508192147
Name:PHILLIP G. KOULTOURIDES, O.D. P.C.
Entity Type:Organization
Organization Name:PHILLIP G. KOULTOURIDES, O.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KOULTOURIDES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-365-8069
Mailing Address - Street 1:9140 DRAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9066
Mailing Address - Country:US
Mailing Address - Phone:219-365-8069
Mailing Address - Fax:219-465-2785
Practice Address - Street 1:2400 MORTHLAND DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8329
Practice Address - Country:US
Practice Address - Phone:219-465-2788
Practice Address - Fax:219-465-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-01
Last Update Date:2009-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty