Provider Demographics
NPI:1588641898
Name:KOSTALLAS, ANTHONY (OD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:KOSTALLAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 PACIFIC BLVD
Mailing Address - Street 2:STE. 104
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4100
Mailing Address - Country:US
Mailing Address - Phone:323-581-4466
Mailing Address - Fax:323-587-8650
Practice Address - Street 1:6325 PACIFIC BLVD
Practice Address - Street 2:STE. 104
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4100
Practice Address - Country:US
Practice Address - Phone:323-581-4466
Practice Address - Fax:323-587-8650
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6482T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0064820Medicaid
CASD0064820Medicaid