Provider Demographics
NPI:1144411414
Name:COUTSOFTIDES, THEODORE (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:COUTSOFTIDES
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 1:4061 MORNING STAR DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3009
Mailing Address - Country:US
Mailing Address - Phone:714-336-7949
Mailing Address - Fax:714-840-6314
Practice Address - Street 1:4061 MORNING STAR DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3009
Practice Address - Country:US
Practice Address - Phone:714-336-7949
Practice Address - Fax:714-840-6314
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-02
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA031348208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA031348OtherLICENCE
020038943OtherRAILROAD MEDICARE