Provider Demographics
NPI:1144439795
Name:KOUTSOUBIS, KOSTAS D (PT)
Entity type:Individual
Prefix:
First Name:KOSTAS
Middle Name:D
Last Name:KOUTSOUBIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16214 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-3109
Mailing Address - Country:US
Mailing Address - Phone:718-939-7171
Mailing Address - Fax:718-661-2057
Practice Address - Street 1:16214 45TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-3109
Practice Address - Country:US
Practice Address - Phone:718-939-7171
Practice Address - Fax:718-661-2057
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0220661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQM7371OtherBCBS
NYQM7371OtherBCBS