Provider Demographics
NPI:1770089849
Name:KOURTJIAN, EVAN (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:KOURTJIAN
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 1:1240 UNIVERSITY BAY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2253
Mailing Address - Country:US
Mailing Address - Phone:734-255-7979
Mailing Address - Fax:
Practice Address - Street 1:1240 UNIVERSITY BAY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2253
Practice Address - Country:US
Practice Address - Phone:734-255-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI722392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry