Healthcare Provider Details

I. General information

NPI: 1417470360
Provider Name (Legal Business Name): BETTY V KOUKIS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 S MAIN ST
MOULTRIE GA
31768-5811
US

IV. Provider business mailing address

30 OAK LN
MOULTRIE GA
31768-5444
US

V. Phone/Fax

Practice location:
  • Phone: 229-785-2335
  • Fax:
Mailing address:
  • Phone: 917-386-5611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: BETTY VASSILIKI KOUKIS
Title or Position: MD
Credential:
Phone: 229-785-2335