Provider Demographics
NPI:1508976770
Name:KOUNTAKIS, STILIANOS E (MD)
Entity Type:Individual
Prefix:
First Name:STILIANOS
Middle Name:E
Last Name:KOUNTAKIS
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 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-828-8401
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:BP-4109
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4400
Practice Address - Fax:706-721-0112
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053256207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA375068228AMedicaid
SCG53256Medicaid
GA04BDCMHMedicare ID - Type UnspecifiedGA MEDICARE
GA375068228AMedicaid