Healthcare Provider Details

I. General information

NPI: 1376676775
Provider Name (Legal Business Name): THERESA KOUO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MONUMENT RD
YORK PA
17403-5074
US

IV. Provider business mailing address

601 MEMORY LN
YORK PA
17402-2231
US

V. Phone/Fax

Practice location:
  • Phone: 717-812-4083
  • Fax: 717-812-2244
Mailing address:
  • Phone: 717-851-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License NumberD0064346
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberMD460536
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD460536
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: