Provider Demographics
NPI:1750479929
Name:KOUKKARI, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:KOUKKARI
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 1:2350 W EL CAMINO REAL
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2577 SAMARITAN DRIVE
Practice Address - Street 2:SUITE 725
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-4552
Practice Address - Country:US
Practice Address - Phone:408-524-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74711174400000X, 2084N0400X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No174400000XOther Service ProvidersSpecialist
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology