Provider Demographics
NPI:1679647465
Name:KOUTELOS, THOMAS N (INTERNAL MEDICINE)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:N
Last Name:KOUTELOS
Suffix:
Gender:M
Credentials:INTERNAL MEDICINE
Other - Prefix:
Other - First Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PLAZA ST W STE 1F
Mailing Address - Street 2:421 78TH STREET BROOKLYN NY 11209
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3942
Mailing Address - Country:US
Mailing Address - Phone:718-622-1025
Mailing Address - Fax:718-622-0915
Practice Address - Street 1:25 PLAZA ST W STE 1F
Practice Address - Street 2:421 78TH STREET BROOKLYN NY 11209
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3942
Practice Address - Country:US
Practice Address - Phone:718-622-1025
Practice Address - Fax:718-622-0915
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19052 1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01366774Medicaid
NY113416490OtherMAGNACARE
NYIC7375OtherACS HEALTHNET OF NE
NYP809058OtherOXFORD
NY10L46OtherEMPIRE BC-BS
NY113416490Other1199
NY113416490OtherPHS
NY190521OtherHIP OF NY
NY2023469OtherAETNA HMO PPO
NY113416490OtherUNITED EMPIRE
NY5699985OtherGHI
NY6638812006OtherCIGNA PPO HMO
NY33D0709729OtherCLEAR#
NY11 0240756OtherRAILROAD MEDICARE
NY113416490OtherUNITED HEALTHCARE
NY113416490OtherMULTI PLAN
NY113416490OtherOTHER UNION