Provider Demographics
NPI:1972614576
Name:KOUCHOUKOS, NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:KOUCHOUKOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 N BALLAS RD STE 150D
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2319
Mailing Address - Country:US
Mailing Address - Phone:314-996-5287
Mailing Address - Fax:314-432-6068
Practice Address - Street 1:3023 N BALLAS RD STE 150D
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2319
Practice Address - Country:US
Practice Address - Phone:314-996-5287
Practice Address - Fax:314-432-6068
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO28052208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202103727Medicaid
A13852Medicare UPIN
MO202103727Medicaid