Provider Demographics
NPI:1700839321
Name:GOUDOUVAS, SOTIRIOS (PA)
Entity Type:Individual
Prefix:MR
First Name:SOTIRIOS
Middle Name:
Last Name:GOUDOUVAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 OAKLAND CT.
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711
Mailing Address - Country:US
Mailing Address - Phone:610-869-5757
Mailing Address - Fax:610-869-6544
Practice Address - Street 1:900 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 103
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-9313
Practice Address - Country:US
Practice Address - Phone:610-869-5757
Practice Address - Fax:610-869-6544
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003215L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA097724Medicare ID - Type Unspecified
P27248Medicare UPIN