Provider Demographics
NPI:1417056847
Name:KOSTAKOS, DEAN P (DPM)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:P
Last Name:KOSTAKOS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 UPPER HEMBREE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1146
Mailing Address - Country:US
Mailing Address - Phone:770-346-7500
Mailing Address - Fax:770-346-8800
Practice Address - Street 1:1380 UPPER HEMBREE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1146
Practice Address - Country:US
Practice Address - Phone:770-346-7500
Practice Address - Fax:770-346-8800
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000605213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Not Answered213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA909671OtherBLUE CROSS BLUE SHIELD
P00166113OtherRAIL ROAD MEDICARE
4407320OtherAETNA HEALTH PLANS
GAU28228OtherCOVENTRY
U28288Medicare UPIN
48SCCQJMedicare ID - Type Unspecified