Provider Demographics
NPI:1437238565
Name:COSTOUROS, JOHN GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GEORGE
Last Name:COSTOUROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 EMBARCADERO RD
Mailing Address - Street 2:STE 100
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-3341
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:
Practice Address - Street 1:450 BROADWAY ST
Practice Address - Street 2:PAVILION C, MC 6342
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3132
Practice Address - Country:US
Practice Address - Phone:650-725-6609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71437207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A714370Medicaid
CA00A714370Medicaid
00A714370Medicare ID - Type Unspecified