Basic Information
| Provider Information | |||||||||
| NPI: | 1235485137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUKOVALAS | ||||||||
| FirstName: | STEFANOS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415000-MSC8156 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372418156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1934 ALCOA HWY STE D362 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653054670 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2012 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | BP20066599 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 208200000X | BP10052157 | TX | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208600000X | MT202718 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208200000X | 62868 | TN | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.