Healthcare Provider Details

I. General information

NPI: 1750479929
Provider Name (Legal Business Name): MARK W. KOUKKARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2577 SAMARITAN DRIVE SUITE 725
SAN JOSE CA
95129-4552
US

IV. Provider business mailing address

2350 W EL CAMINO REAL 2ND FLOOR
MOUNTAIN VIEW CA
94040-6201
US

V. Phone/Fax

Practice location:
  • Phone: 408-524-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG74711
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG74711
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberG74711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: