Provider Demographics
NPI:1316982218
Name:KOUMPOURAS, FOTIOS (M D)
Entity type:Individual
Prefix:DR
First Name:FOTIOS
Middle Name:
Last Name:KOUMPOURAS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 DEVINE ST
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2195
Mailing Address - Country:US
Mailing Address - Phone:203-737-5430
Mailing Address - Fax:203-785-7053
Practice Address - Street 1:6 DEVINE ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2195
Practice Address - Country:US
Practice Address - Phone:203-737-5430
Practice Address - Fax:203-785-7053
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042299207RR0500X
NY230675207R00000X
PAMD431644207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019099240003Medicaid
CTI48820Medicare UPIN
PA111184PL2Medicare PIN