Provider Demographics
NPI:1558304915
Name:KOUSA, KITTA (MD)
Entity Type:Individual
Prefix:
First Name:KITTA
Middle Name:
Last Name:KOUSA
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:P.O. BOX #336
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240
Mailing Address - Country:US
Mailing Address - Phone:606-226-6667
Mailing Address - Fax:606-789-6202
Practice Address - Street 1:538 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240
Practice Address - Country:US
Practice Address - Phone:606-226-6667
Practice Address - Fax:606-789-3811
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39229207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64113913Medicaid
I42159Medicare UPIN
KY00054001Medicare PIN