=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548446883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK COSTOPOULOS DPM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2008
-----------------------------------------------------
Last Update Date | 02/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6333 WILSHIRE BLVD SUITE 304
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-376-3668
-----------------------------------------------------
Fax | 310-376-8777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6333 WILSHIRE BLVD SUITE 304
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-376-3668
-----------------------------------------------------
Fax | 310-376-8777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PODIATRIST
-----------------------------------------------------
Name | MARK COSTOPOULOS
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 310-376-3668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | E2607
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------