=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366639262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELOS KOUTSONIKOLIS MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2007
-----------------------------------------------------
Last Update Date | 04/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10075 JOG RD SUITE 100
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-733-3546
-----------------------------------------------------
Fax | 561-733-3547
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10075 JOG RD SUITE 100
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-733-3546
-----------------------------------------------------
Fax | 561-733-3547
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANGELOS KOUTSONIKOLIS
-----------------------------------------------------
Credential | MEDICAL DOCTOR
-----------------------------------------------------
Telephone | 561-733-3546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number | ME63824
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------