Basic Information
| Provider Information | |||||||||
| NPI: | 1972571297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTIDAKIS | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | P | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | 7654491196 | ||||||||
| Practice Location | |||||||||
| Address1: | 2606 VETERANS MEMORIAL PKWY S STE 8 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479099192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654474776 | ||||||||
| FaxNumber: | 7654474809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2006 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 07000748A | IN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 100232960 | 05 | IN | MEDICAID | 10781139 | 01 | IN | CAQH | OTHER | 480034530 | 01 | IN | MEDICARE RAILROAD NUMBER | OTHER | 000000247376 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER |