Provider Demographics
NPI:1205331089
Name:KOUTSOGIANNIS, PETROS (DO)
Entity type:Individual
Prefix:DR
First Name:PETROS
Middle Name:
Last Name:KOUTSOGIANNIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2248
Mailing Address - Fax:
Practice Address - Street 1:1604 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5524
Practice Address - Country:US
Practice Address - Phone:910-276-4611
Practice Address - Fax:910-277-4244
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-01911207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty