Basic Information
| Provider Information | |||||||||
| NPI: | 1033157219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOTOPOULOS | ||||||||
| FirstName: | COSTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | R.D., M.S., C.N.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2726 FRANCIS LEWIS BLVD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113581147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183585765 | ||||||||
| FaxNumber: | 7183585765 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 POLY PL | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112097104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188366600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 04/15/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 000412-1 | NY | Y | Dietary & Nutritional Service Providers | Nutritionist |
ID Information
| ID | Type | State | Issuer | Description | 78P0031 | 01 | NY | NYPCHP | OTHER | P467422 | 01 | NY | OXFORD HEALTH PLANS | OTHER | 000412-1 | 01 | NY | CERTIFIED NUTRITIONIST | OTHER |