Healthcare Provider Details

I. General information

NPI: 1780673749
Provider Name (Legal Business Name): CHRISTO W KOULISIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 COLLEGE BLVD W SUITE 4
NICEVILLE FL
32578-1060
US

IV. Provider business mailing address

1003 COLLEGE BLVD W STE 4
NICEVILLE FL
32578-1060
US

V. Phone/Fax

Practice location:
  • Phone: 850-279-6789
  • Fax: 850-279-6546
Mailing address:
  • Phone: 850-279-6789
  • Fax: 850-279-6546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301503101
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0053933
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: