Provider Demographics
NPI:1992986509
Name:KOULLIAS, GEORGE JOHN (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:JOHN
Last Name:KOULLIAS
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 1:100 HOSPITAL RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-8809
Mailing Address - Country:US
Mailing Address - Phone:631-438-5030
Mailing Address - Fax:631-447-5954
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-8809
Practice Address - Country:US
Practice Address - Phone:631-438-5030
Practice Address - Fax:631-447-5954
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119605208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03619605OtherIL LICENSE
CT039729OtherCT LICENSE
NY262079OtherMEDICAL BOARD-NY STATE