Provider Demographics
NPI:1508387499
Name:KAOUTZANI, LYDIA (MD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:KAOUTZANI
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 1:110 FRANCIS ST STE 9B
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5501
Mailing Address - Country:US
Mailing Address - Phone:617-632-9511
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST. BI
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-5501
Practice Address - Country:US
Practice Address - Phone:706-721-7124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA272276208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery