Provider Demographics
NPI:1952379265
Name:KOUTENTIS, CHRISTOS A (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOS
Middle Name:A
Last Name:KOUTENTIS
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:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-0758
Mailing Address - Country:US
Mailing Address - Phone:973-779-7361
Mailing Address - Fax:973-779-7385
Practice Address - Street 1:350 BOULEVARD
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-2840
Practice Address - Country:US
Practice Address - Phone:973-779-7361
Practice Address - Fax:973-779-7385
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92701207L00000X
NJ25MA08011500207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02010YMedicare ID - Type Unspecified
NJI28386Medicare UPIN
NJ109678Medicare ID - Type Unspecified
FL0210ZMedicare ID - Type Unspecified