Provider Demographics
NPI:1609439694
Name:KOUTLAS, NATHANIEL THEODORE (MD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:THEODORE
Last Name:KOUTLAS
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:9650 GROSS POINT RD
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-5080
Mailing Address - Country:US
Mailing Address - Phone:847-866-7846
Mailing Address - Fax:224-251-2905
Practice Address - Street 1:9650 GROSS POINT RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-5080
Practice Address - Country:US
Practice Address - Phone:847-866-7846
Practice Address - Fax:224-251-2905
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036169038207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty