MEDICARE: KOSTA A. KOUTOULAS, OD INC

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

General Provider Information

NPI Number	:	1760295422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOSTA A. KOUTOULAS, OD INC

Provider Business Mailing 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	:	650-757-8032

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	:	650-757-8032

Authorized Official
Title or Position	:	PROVIDER/CEO
Name	:	DR. KOSTA A KOUTOULAS
Credential	:	OD
Telephone Number	:	650-757-8286

Provider Enumeration Date	:	01/28/2025
Last Update Date	:	01/30/2025

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