1972571297 NPI number — NICHOLAS P COSTIDAKIS DPM

Table of content: NICHOLAS P COSTIDAKIS DPM (NPI 1972571297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972571297 NPI number — NICHOLAS P COSTIDAKIS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTIDAKIS
Provider First Name:
NICHOLAS
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972571297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47903-4699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-449-2732
Provider Business Mailing Address Fax Number:
765-449-1196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2606 VETERANS MEMORIAL PKWY S STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47909-9192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-447-4776
Provider Business Practice Location Address Fax Number:
765-447-4809
Provider Enumeration Date:
03/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  07000748A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100232960 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10781139 . This is a "CAQH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 480034530 . This is a "MEDICARE RAILROAD NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000247376 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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