Provider Demographics
NPI:1780673749
Name:KOULISIS, CHRISTO W (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTO
Middle Name:W
Last Name:KOULISIS
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 1:1003 COLLEGE BLVD W STE 4
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1060
Mailing Address - Country:US
Mailing Address - Phone:850-279-6789
Mailing Address - Fax:850-279-6546
Practice Address - Street 1:1003 COLLEGE BLVD W
Practice Address - Street 2:SUITE 4
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1060
Practice Address - Country:US
Practice Address - Phone:850-279-6789
Practice Address - Fax:850-279-6546
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301503101207X00000X
FLME0053933174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07915OtherBLUE CROSS BLUE SHIELD
FL162510700OtherDEPARTMENT OF LABOR
FL256355000Medicaid
FL162510700OtherDEPARTMENT OF LABOR
B24093Medicare UPIN