Provider Demographics
NPI:1659360931
Name:KOURTU, MOHAMED A (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:A
Last Name:KOURTU
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 1:2 W CRESCENT PARK
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2111
Mailing Address - Country:US
Mailing Address - Phone:814-723-3300
Mailing Address - Fax:814-723-8515
Practice Address - Street 1:2 W CRESCENT PARK
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2111
Practice Address - Country:US
Practice Address - Phone:814-723-3300
Practice Address - Fax:814-723-8515
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049485L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001819996Medicaid
045461Medicare ID - Type Unspecified
PA001819996Medicaid