1326133646 NPI number — HARITON KOUSOUROU M.D.

Table of content: HARITON KOUSOUROU M.D. (NPI 1326133646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326133646 NPI number — HARITON KOUSOUROU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOUSOUROU
Provider First Name:
HARITON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326133646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
452 HEALTH PARKWAY
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
PAW PAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-655-3080
Provider Business Mailing Address Fax Number:
269-655-0761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 ROUTE 25A
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SHOREHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11786-1389
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-821-2626
Provider Business Practice Location Address Fax Number:
631-744-1627
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  156800 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01026700 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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