Provider Demographics
NPI:1467482521
Name:KAPORDELIS, KONSTANTINOS (MD)
Entity Type:Individual
Prefix:
First Name:KONSTANTINOS
Middle Name:
Last Name:KAPORDELIS
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 1:21421 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3215
Mailing Address - Country:US
Mailing Address - Phone:586-779-9899
Mailing Address - Fax:586-773-7800
Practice Address - Street 1:21421 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3215
Practice Address - Country:US
Practice Address - Phone:586-779-9899
Practice Address - Fax:586-773-7800
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI041225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4690260 10Medicaid
A78052Medicare UPIN
0P09250Medicare ID - Type Unspecified