Provider Demographics
NPI:1588641898
Name:KOSTALLAS, ANTHONY (OD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:KOSTALLAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 PACIFIC BLVD
Mailing Address - Street 2:STE. 104
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4100
Mailing Address - Country:US
Mailing Address - Phone:323-581-4466
Mailing Address - Fax:323-587-8650
Practice Address - Street 1:6325 PACIFIC BLVD
Practice Address - Street 2:STE. 104
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4100
Practice Address - Country:US
Practice Address - Phone:323-581-4466
Practice Address - Fax:323-587-8650
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6482T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0064820Medicaid
CASD0064820Medicaid