Provider Demographics
NPI:1295818680
Name:KOUTSOS, MARKOS I (MD)
Entity type:Individual
Prefix:
First Name:MARKOS
Middle Name:I
Last Name:KOUTSOS
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 1:421 78TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3403
Mailing Address - Country:US
Mailing Address - Phone:718-491-0706
Mailing Address - Fax:718-491-0732
Practice Address - Street 1:421 78TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3403
Practice Address - Country:US
Practice Address - Phone:718-491-0706
Practice Address - Fax:718-491-0732
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187114174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY26N342Medicare ID - Type Unspecified
NYG40068Medicare UPIN