Provider Demographics
NPI:1144310756
Name:KOURETAS, PETER CRIST (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:CRIST
Last Name:KOURETAS
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 1:550 16TH ST FL 5
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2549
Mailing Address - Country:US
Mailing Address - Phone:415-476-3535
Mailing Address - Fax:415-476-5365
Practice Address - Street 1:550 16TH ST FL 5
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143
Practice Address - Country:US
Practice Address - Phone:415-476-3535
Practice Address - Fax:415-476-3535
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-096431208G00000X, 208G00000X
UT5686701-1205208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHKO4301751Medicare PIN
OH3072044Medicaid