1780673749 NPI number — CHRISTO W KOULISIS MD

Table of content: CHRISTO W KOULISIS MD (NPI 1780673749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780673749 NPI number — CHRISTO W KOULISIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOULISIS
Provider First Name:
CHRISTO
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1780673749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1003 COLLEGE BLVD W STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NICEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32578-1060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-279-6789
Provider Business Mailing Address Fax Number:
850-279-6546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1003 COLLEGE BLVD W
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-1060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-279-6789
Provider Business Practice Location Address Fax Number:
850-279-6546
Provider Enumeration Date:
10/20/2005

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: 207X00000X , with the licence number:  4301503101 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: ME0053933 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07915 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 162510700 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 256355000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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