Healthcare Provider Details

I. General information

NPI: 1669477717
Provider Name (Legal Business Name): MARK COSTOPOULOS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 N SEPULVEDA BLVD
MANHATTAN BEACH CA
90266-5921
US

IV. Provider business mailing address

608 N SEPULVEDA BLVD
MANHATTAN BEACH CA
90266-5921
US

V. Phone/Fax

Practice location:
  • Phone: 310-376-3668
  • Fax: 310-376-8777
Mailing address:
  • Phone: 310-376-3668
  • Fax: 310-376-8777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE2607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: