Provider Demographics
NPI:1972664829
Name:GOUTOS, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:GOUTOS
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 1:22 N SERVICE RD BLDG 22A
Mailing Address - Street 2:JFK INT'L AIRPORT
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11430-1618
Mailing Address - Country:US
Mailing Address - Phone:718-244-1644
Mailing Address - Fax:718-244-1622
Practice Address - Street 1:22 N SERVICE RD BLDG 22A
Practice Address - Street 2:JFK INT'L AIRPORT
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11430-1618
Practice Address - Country:US
Practice Address - Phone:718-244-1644
Practice Address - Fax:718-244-1622
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164125207R00000X, 208D00000X, 2083X0100X
PAMD041171E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0000153322807OtherUNITED HEALTHCARE
NY030052OtherEMPIRE BLUE CROSS BLUE SH
NY874335OtherAETNA
NY2590520OtherGHI
NY2590520OtherGHI
A64532Medicare UPIN