Healthcare Provider Details

I. General information

NPI: 1508976770
Provider Name (Legal Business Name): STILIANOS E. KOUNTAKIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST BP-4109
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1499 WALTON WAY STE 1400
AUGUSTA GA
30901-2602
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4400
  • Fax: 706-721-0112
Mailing address:
  • Phone: 706-828-8401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number053256
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: