Healthcare Provider Details

I. General information

NPI: 1194932079
Provider Name (Legal Business Name): KOSTAS JOHN ECONOMOPOULOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 E HIGHLAND AVE SUITE 300
PHOENIX AZ
85016-4879
US

IV. Provider business mailing address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5452
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-6211
  • Fax: 866-242-5309
Mailing address:
  • Phone: 480-301-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number43879
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: