Provider Demographics
NPI:1902898331
Name:KOUTLAS, THEODORE C (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:C
Last Name:KOUTLAS
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 1:62 W 7TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2321
Mailing Address - Country:US
Mailing Address - Phone:509-456-0262
Mailing Address - Fax:509-462-5059
Practice Address - Street 1:62 W 7TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2321
Practice Address - Country:US
Practice Address - Phone:509-456-0262
Practice Address - Fax:509-462-5059
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12098208G00000X
NC36754208G00000X
WAMD60367366208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC330004170OtherRAILROAD MEDICARE
NC8950281Medicaid
NC50281OtherBCBS NC
ID20003883Medicare PIN
NC50281OtherBCBS NC
NC2223678Medicare PIN