Provider Demographics
NPI:1821154790
Name:GOUGOUTAS, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GOUGOUTAS
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 1:1145 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4201
Mailing Address - Country:US
Mailing Address - Phone:206-860-5414
Mailing Address - Fax:
Practice Address - Street 1:1229 MADISON ST # 1660
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3586
Practice Address - Country:US
Practice Address - Phone:206-860-5582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD602761022086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1821154790Medicaid
WA8909038OtherMEDICARE PIN