Provider Demographics
NPI:1184729253
Name:KOUCHIS, NICHOLAS SPERO (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:SPERO
Last Name:KOUCHIS
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 1:8144 E LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-9204
Mailing Address - Country:US
Mailing Address - Phone:630-244-7656
Mailing Address - Fax:
Practice Address - Street 1:8144 E LAUREL ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-9204
Practice Address - Country:US
Practice Address - Phone:630-244-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
IL036089784207Q00000X
AZ63760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG11829Medicare UPIN
IL593680Medicare ID - Type Unspecified