Provider Demographics
NPI:1669477717
Name:COSTOPOULOS, MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:COSTOPOULOS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 N SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5921
Mailing Address - Country:US
Mailing Address - Phone:310-376-3668
Mailing Address - Fax:310-376-8777
Practice Address - Street 1:608 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5921
Practice Address - Country:US
Practice Address - Phone:310-376-3668
Practice Address - Fax:310-376-8777
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2607213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E26070Medicaid
CAE2607AOtherMEDICARE LICENSE
CA000E26070Medicaid
CA3871470002Medicare NSC