Provider Demographics
NPI:1033157219
Name:FOTOPOULOS, COSTA (RD, MS, CNS)
Entity Type:Individual
Prefix:MR
First Name:COSTA
Middle Name:
Last Name:FOTOPOULOS
Suffix:
Gender:M
Credentials:RD, MS, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2726 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1147
Mailing Address - Country:US
Mailing Address - Phone:718-358-5765
Mailing Address - Fax:718-358-5765
Practice Address - Street 1:800 POLY PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7104
Practice Address - Country:US
Practice Address - Phone:718-836-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000412-1133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY78P0031OtherNYPCHP
NYP467422OtherOXFORD HEALTH PLANS
NY000412-1OtherCERTIFIED NUTRITIONIST