Provider Demographics
NPI:1922206762
Name:KOUKIS, BETTY VASSILIKI (MD)
Entity Type:Individual
Prefix:DR
First Name:BETTY
Middle Name:VASSILIKI
Last Name:KOUKIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6902
Mailing Address - Country:US
Mailing Address - Phone:334-671-9445
Mailing Address - Fax:334-836-0059
Practice Address - Street 1:1405 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-5811
Practice Address - Country:US
Practice Address - Phone:229-785-2335
Practice Address - Fax:229-785-2336
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090876207V00000X
GA066134207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003110693AMedicaid