Provider Demographics
NPI:1235398421
Name:DIMITRIOS KOSTOPOULOS PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:DIMITRIOS KOSTOPOULOS PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIMITRIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:PT PHD DSC
Authorized Official - Phone:718-707-6970
Mailing Address - Street 1:3270 31ST ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2643
Mailing Address - Country:US
Mailing Address - Phone:718-707-6970
Mailing Address - Fax:718-732-2864
Practice Address - Street 1:8012 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3802
Practice Address - Country:US
Practice Address - Phone:718-491-5454
Practice Address - Fax:718-491-2995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0111881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100000482Medicare PIN