Provider Demographics
NPI:1629136999
Name:KOUYOUMDJIAN, MARC A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:KOUYOUMDJIAN
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:12255 FAIR LAKES PKWY
Practice Address - Street 2:KAISER PERMANENTE FAIR OAKS MEDICAL CENTER
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3952
Practice Address - Country:US
Practice Address - Phone:703-934-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101229954207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G34094Medicare UPIN
010954M92Medicare ID - Type Unspecified