Provider Demographics
NPI:1972571297
Name:COSTIDAKIS, NICHOLAS P (DPM)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:P
Last Name:COSTIDAKIS
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:2606 VETERANS MEMORIAL PKWY S STE 8
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-9192
Practice Address - Country:US
Practice Address - Phone:765-447-4776
Practice Address - Fax:765-447-4809
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000748A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100232960Medicaid
IN10781139OtherCAQH
IN480034530OtherMEDICARE RAILROAD NUMBER
IN000000247376OtherANTHEM PROVIDER NUMBER
IN10781139OtherCAQH
IN000000247376OtherANTHEM PROVIDER NUMBER