Provider Demographics
NPI:1730250655
Name:KOSTAS, ODYSSEAS DEMOSTHENES (MD)
Entity type:Individual
Prefix:DR
First Name:ODYSSEAS
Middle Name:DEMOSTHENES
Last Name:KOSTAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CHURCH ST
Mailing Address - Street 2:APT A40
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5631
Mailing Address - Country:US
Mailing Address - Phone:203-869-7005
Mailing Address - Fax:
Practice Address - Street 1:2 HALF DEARFIELD DRIVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831
Practice Address - Country:US
Practice Address - Phone:203-869-0698
Practice Address - Fax:203-869-5817
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH74945Medicare UPIN