Provider Demographics
NPI:1972565901
Name:KOUTROUPAS, STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:KOUTROUPAS
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 1:9647 WYOMING TER S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1606
Mailing Address - Country:US
Mailing Address - Phone:612-867-4368
Mailing Address - Fax:
Practice Address - Street 1:2855 CAMPUS DR STE 630
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2665
Practice Address - Country:US
Practice Address - Phone:763-233-5755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24325207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN178075100Medicaid
MN178075100Medicaid