Healthcare Provider Details

I. General information

NPI: 1235252396
Provider Name (Legal Business Name): A&K KOUKLAKIS OD. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2294 W LINCOLN HWY
MERRILLVILLE IN
46410
US

IV. Provider business mailing address

2294 W LINCOLN HWY
MERRILLVILLE IN
46410
US

V. Phone/Fax

Practice location:
  • Phone: 219-756-1700
  • Fax: 219-756-8718
Mailing address:
  • Phone: 219-756-1700
  • Fax: 219-756-8718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ALEXANDER HARIDIMOS KOUKLAKIS
Title or Position: PRESIDENT
Credential: OD
Phone: 219-756-1700