=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609938539
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOSTA A. KOUTOULAS O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 10/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7380 MISSION ST
-----------------------------------------------------
City | DALY CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94014-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-757-8286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3099 RIVERA DR
-----------------------------------------------------
City | BURLINGAME
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94010-5833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-218-8580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 13085
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------