Healthcare Provider Details

I. General information

NPI: 1801868658
Provider Name (Legal Business Name): CONSTANTINOS CHRYSOSTOMOU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17360 BROOKHURST STREET ATTN: NETWORK MANAGEMENT
FOUNTAIN VALLEY CA
92708-3720
US

IV. Provider business mailing address

17360 BROOKHURST STREET ATTN: NETWORK MANAGEMENT
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 714-377-2900
  • Fax:
Mailing address:
  • Phone: 714-377-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD426904
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME126009
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberC129462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: