Provider Demographics
NPI:1609813880
Name:KOSTOPOULOS, KIMON ALEXANDER (DO)
Entity Type:Individual
Prefix:
First Name:KIMON
Middle Name:ALEXANDER
Last Name:KOSTOPOULOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 538
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-0538
Mailing Address - Country:US
Mailing Address - Phone:215-741-3510
Mailing Address - Fax:215-741-3519
Practice Address - Street 1:825 TOWN CENTER DRIVE
Practice Address - Street 2:SUITE 152
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-3030
Practice Address - Country:US
Practice Address - Phone:215-741-3510
Practice Address - Fax:215-741-3519
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012128207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019054860003Medicaid
PA094050Medicare ID - Type Unspecified
PA0019054860003Medicaid