Provider Demographics
NPI:1699255406
Name:KOULLIAS, MICHAEL ANTONIS
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTONIS
Last Name:KOULLIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 66TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-5939
Mailing Address - Country:US
Mailing Address - Phone:646-642-6269
Mailing Address - Fax:
Practice Address - Street 1:1070 66TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-5939
Practice Address - Country:US
Practice Address - Phone:646-642-6269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4175222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist