Healthcare Provider Details

I. General information

NPI: 1215632682
Provider Name (Legal Business Name): SOFIA GKOULGKOUNTINA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6480 WEDDINGTON RD
WESLEY CHAPEL NC
28104-6277
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-5650
  • Fax: 704-316-5651
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2025-00191
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: