Provider Demographics
NPI:1568466928
Name:COSTAKOS, DEBORAH (MD)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:
Last Name:COSTAKOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC OPHTHALMOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-607-5280
Mailing Address - Fax:414-266-2027
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC OPHTHALMOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-607-5280
Practice Address - Fax:414-266-2027
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI41333-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568466928Medicaid
WI73601 1903Medicare PIN
WIH65626Medicare UPIN
WI462200003Medicare ID - Type Unspecified
WI68086 0422Medicare PIN