MEDICARE: DR. MARK COSTOPOULOS D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	E2607	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	E2607A	OTHER	CA	MEDICARE LICENSE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669477717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK COSTOPOULOS D.P.M.

Provider Business Mailing Address
First Line	:	608 N SEPULVEDA BLVD
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5921
Country	:	US
Telephone Number	:	310-376-3668
Fax Number	:	310-376-8777

Provider Business Practice Location Address
First Line	:	608 N SEPULVEDA BLVD
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5921
Country	:	US
Telephone Number	:	310-376-3668
Fax Number	:	310-376-8777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	10/27/2008

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