Provider Demographics
NPI:1255402749
Name:DIMITRIOS KOTSOPULOS, D.P.M., P.C.
Entity type:Organization
Organization Name:DIMITRIOS KOTSOPULOS, D.P.M., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIMITRIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTSOPULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-923-9630
Mailing Address - Street 1:12400 S HARLEM AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1476
Mailing Address - Country:US
Mailing Address - Phone:708-923-9630
Mailing Address - Fax:
Practice Address - Street 1:12400 S HARLEM AVE STE 201
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1476
Practice Address - Country:US
Practice Address - Phone:708-923-9630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01637213OtherBC/BS OF IL GROUP #
IL01637213OtherBC/BS OF IL GROUP #
IN200850Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
IL214318Medicare PIN
IL4719620001Medicare NSC