Provider Demographics
NPI:1609439694
Name:KOUTLAS, NATHANIEL THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:THEODORE
Last Name:KOUTLAS
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 1:5147 BARBEE CHAPEL RD APT 205
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-6227
Mailing Address - Country:US
Mailing Address - Phone:252-413-9656
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR RM 1017
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4226
Practice Address - Country:US
Practice Address - Phone:984-974-1072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC250584390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty