Provider Demographics
NPI:1073599775
Name:KOSTIC, JASMINKA (MD)
Entity Type:Individual
Prefix:
First Name:JASMINKA
Middle Name:
Last Name:KOSTIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3406
Mailing Address - Country:US
Mailing Address - Phone:773-588-6680
Mailing Address - Fax:773-588-6451
Practice Address - Street 1:3114 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3406
Practice Address - Country:US
Practice Address - Phone:773-588-6680
Practice Address - Fax:773-588-6451
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104292207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104292Medicaid
H39100Medicare UPIN
IL210125Medicare ID - Type UnspecifiedGROUP
IL036104292Medicaid