Healthcare Provider Details

I. General information

NPI: 1124027172
Provider Name (Legal Business Name): PAUL R KOUYOUMDJI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 BY PASS RD SUITE 101
SALEM NJ
08079-2053
US

IV. Provider business mailing address

PO BOX 504290
SAINT LOUIS MO
63150-0001
US

V. Phone/Fax

Practice location:
  • Phone: 856-935-3582
  • Fax: 856-935-4382
Mailing address:
  • Phone: 856-935-3582
  • Fax: 856-935-4382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA64453
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: