MEDICARE: NICHOLAS P COSTIDAKIS DPM

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	07000748A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	480034530	OTHER	IN	MEDICARE RAILROAD NUMBER

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
2	10781139	OTHER	IN	CAQH
4	000000247376	OTHER	IN	ANTHEM PROVIDER NUMBER

General Provider Information

NPI Number	:	1972571297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS P COSTIDAKIS DPM

Provider Business Mailing Address
First Line	:	PO BOX 4699
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47903-4699
Country	:	US
Telephone Number	:	765-449-2732
Fax Number	:	765-449-1196

Provider Business Practice Location Address
First Line	:	2606 VETERANS MEMORIAL PKWY S STE 8
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-9192
Country	:	US
Telephone Number	:	765-447-4776
Fax Number	:	765-447-4809

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

Provider Enumeration Date	:	03/11/2006
Last Update Date	:	03/22/2021

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Directions to “ NICHOLAS P COSTIDAKIS DPM” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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