Basic Information
| Provider Information | |||||||||
| NPI: | 1801868658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRYSOSTOMOU | ||||||||
| FirstName: | CONSTANTINOS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17360 BROOKHURST STREET | ||||||||
| Address2: | ATTN: NETWORK MANAGEMENT | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927083720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143772900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17360 BROOKHURST STREET | ||||||||
| Address2: | ATTN: NETWORK MANAGEMENT | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927083720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143772900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD426904 | PA | N | Other Service Providers | Specialist | 2080P0202X | ME126009 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | C129462 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 101479082 | 05 | PA | MEDICAID | 016288000 | 05 | FL | MEDICAID |