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General NPI Number Information
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NPI Number | 1235485137
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Entity Type | Individual
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Provider Name | STEFANOS BOUKOVALAS M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/28/2012
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Last Update Date | 04/11/2022
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Provider Practice Location Address
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Address Line | 1934 ALCOA HWY STE D362
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City | KNOXVILLE
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State | TN
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Zip | 37920-1524
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Country | US
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Telephone | 865-305-4670
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 415000-MSC8156
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City | NASHVILLE
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State | TN
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Zip | 37241-8156
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Country | US
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Telephone | 865-670-6199
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Fax | 865-670-6198
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | BP20066599
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | BP10052157
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MT202718
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 62868
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License Number State | TN
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