Healthcare Provider Details

I. General information

NPI: 1821559709
Provider Name (Legal Business Name): ANDREW GUST KOUSTENIS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST # C-246
LEXINGTON KY
40536-0293
US

IV. Provider business mailing address

800 ROSE ST # C-246
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-6162
  • Fax: 859-257-8934
Mailing address:
  • Phone: 859-323-6162
  • Fax: 859-257-8934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01090399A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: