Provider Demographics
NPI:1093924359
Name:KOSTRZEWA, JOHN P (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:KOSTRZEWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 18066
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-8066
Mailing Address - Country:US
Mailing Address - Phone:256-536-9300
Mailing Address - Fax:256-535-9032
Practice Address - Street 1:1963 MEMORIAL PARKWAY SW
Practice Address - Street 2:SUITE 5
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-536-9300
Practice Address - Fax:256-535-9032
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL27811207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51107582OtherBLUECROSS BLUESHIELD OF AL
AL1437279601Medicaid
AL51103360OtherBLUECROSS BLUESHIELD OF AL