Provider Demographics
NPI:1235485137
Name:BOUKOVALAS, STEFANOS (MD)
Entity type:Individual
Prefix:DR
First Name:STEFANOS
Middle Name:
Last Name:BOUKOVALAS
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:PO BOX 415000-MSC8156
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37241-8156
Mailing Address - Country:US
Mailing Address - Phone:865-670-6199
Mailing Address - Fax:865-670-6198
Practice Address - Street 1:1934 ALCOA HWY STE D362
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1524
Practice Address - Country:US
Practice Address - Phone:865-305-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-28
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP20066599208200000X
TXBP10052157208200000X
PAMT202718208600000X
TN62868208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty