MEDICARE: MR. SOTIRIOS GOUDOUVAS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MA003215L	PA

General Provider Information

NPI Number	:	1700839321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SOTIRIOS GOUDOUVAS PA

Provider Business Mailing Address
First Line	:	1101 OAKLAND CT.
Second Line	:
City	:	NEWARK
State	:	DE
Zip	:	19711
Country	:	US
Telephone Number	:	610-869-5757
Fax Number	:	610-869-6544

Provider Business Practice Location Address
First Line	:	900 W BALTIMORE PIKE
Second Line	:	SUITE 103
City	:	WEST GROVE
State	:	PA
Zip	:	19390-9313
Country	:	US
Telephone Number	:	610-869-5757
Fax Number	:	610-869-6544

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	02/16/2012

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