Healthcare Provider Details

I. General information

NPI: 1528064482
Provider Name (Legal Business Name): PETER J. COUTLAKIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JOHNSTON WILLIS DR STE 1200
RICHMOND VA
23235-4730
US

IV. Provider business mailing address

1401 JOHNSTON WILLIS DR STE 1200
RICHMOND VA
23235-4730
US

V. Phone/Fax

Practice location:
  • Phone: 804-323-1401
  • Fax: 804-323-1850
Mailing address:
  • Phone: 804-323-1401
  • Fax: 804-323-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number0101053577
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: