Provider Demographics
NPI:1649356270
Name:KOSTAS, MICHAEL JOHN (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KOSTAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 COBB LN SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-2003
Mailing Address - Country:US
Mailing Address - Phone:678-595-1036
Mailing Address - Fax:770-436-1215
Practice Address - Street 1:2810 COBB LN SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-2003
Practice Address - Country:US
Practice Address - Phone:678-595-1036
Practice Address - Fax:770-436-1215
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR001876111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU52011Medicare UPIN