MEDICARE: A&K KOUKLAKIS OD P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier
2	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700909884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A&K KOUKLAKIS OD P.C.

Provider Business Mailing Address
First Line	:	4902 INDIANAPOLIS BLVD
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3605
Country	:	US
Telephone Number	:	219-398-2066
Fax Number	:	219-398-2066

Provider Business Practice Location Address
First Line	:	4902 INDIANAPOLIS BLVD
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3605
Country	:	US
Telephone Number	:	219-398-2066
Fax Number	:	219-398-2066

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALEXANDER HARIDIMOS KOUKLAKIS
Credential	:	OD
Telephone Number	:	219-756-1700

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	11/03/2010

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