Provider Demographics
NPI:1548446883
Name:MARK COSTOPOULOS DPM
Entity type:Organization
Organization Name:MARK COSTOPOULOS DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-376-3668
Mailing Address - Street 1:6333 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5702
Mailing Address - Country:US
Mailing Address - Phone:310-376-3668
Mailing Address - Fax:310-376-8777
Practice Address - Street 1:6333 WILSHIRE BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5702
Practice Address - Country:US
Practice Address - Phone:310-376-3668
Practice Address - Fax:310-376-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2607213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4800033100OtherRAILROAD MEDICARE
CAE2607BOtherMEDICARE LICENSE
CA000E26071Medicaid
CA000E26071Medicaid
CA3871470001Medicare NSC