MEDICARE: DR. KOSTA A. KOUTOULAS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	13085	CA

General Provider Information

NPI Number	:	1609938539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KOSTA A. KOUTOULAS O.D.

Provider Business Mailing Address
First Line	:	3099 RIVERA DR
Second Line	:
City	:	BURLINGAME
State	:	CA
Zip	:	94010-5833
Country	:	US
Telephone Number	:	650-218-8580
Fax Number	:

Provider Business Practice Location Address
First Line	:	7380 MISSION ST
Second Line	:
City	:	DALY CITY
State	:	CA
Zip	:	94014-2666
Country	:	US
Telephone Number	:	650-757-8286
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	10/04/2012

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