Healthcare Provider Details

I. General information

NPI: 1437161254
Provider Name (Legal Business Name): DIMITRIOS KOTSOPULOS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 S HARLEM AVE STE 201
PALOS HEIGHTS IL
60463-1476
US

IV. Provider business mailing address

12400 S HARLEM AVE STE 201
PALOS HEIGHTS IL
60463-1476
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-9630
  • Fax:
Mailing address:
  • Phone: 708-923-9630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016-004977
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000916A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016-004977
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07000916A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: