Healthcare Provider Details

I. General information

NPI: 1972565901
Provider Name (Legal Business Name): STEVEN KOUTROUPAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 CAMPUS DR STE 630
PLYMOUTH MN
55441-2665
US

IV. Provider business mailing address

9647 WYOMING TER S
BLOOMINGTON MN
55438-1606
US

V. Phone/Fax

Practice location:
  • Phone: 763-233-5755
  • Fax:
Mailing address:
  • Phone: 612-867-4368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number24325
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: