Provider Demographics
NPI:1861138505
Name:KOOKOOTSEDES MEDICAL PC
Entity type:Organization
Organization Name:KOOKOOTSEDES MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOOKOOTSEDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-535-4001
Mailing Address - Street 1:25411 CABOT RD STE 109
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5517
Mailing Address - Country:US
Mailing Address - Phone:949-535-4001
Mailing Address - Fax:949-535-4002
Practice Address - Street 1:25411 CABOT RD STE 109
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5517
Practice Address - Country:US
Practice Address - Phone:949-535-4001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty