Provider Demographics
NPI:1053590141
Name:KOUTNIK, ALFRED V
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:V
Last Name:KOUTNIK
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 1:402 LAMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMO HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:78209-3640
Mailing Address - Country:US
Mailing Address - Phone:719-989-8338
Mailing Address - Fax:
Practice Address - Street 1:230 W SUNSET RD
Practice Address - Street 2:
Practice Address - City:ALAMO HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:78209-2872
Practice Address - Country:US
Practice Address - Phone:719-989-8338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1386797225100000X
COCO 2898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65135512Medicaid
COC501708Medicare PIN