Basic Information
| Provider Information | |||||||||
| NPI: | 1427095520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANOUTAS | ||||||||
| FirstName: | CONSTANTINE | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11 MILLS AVENUE | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642323668 | ||||||||
| FaxNumber: | 8642710526 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 MILLS AVENUE | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642323668 | ||||||||
| FaxNumber: | 8642710526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | SC520 | SC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | SC520 | SC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | SC520 | SC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213EP1101X | SC520 | SC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | D593 | 01 | SC | MEDICARE PTAN | OTHER | GP9955 | 05 | SC | MEDICAID |