Provider Demographics
NPI:1154317600
Name:KOSTRZEWA, DARIUSZ (MD)
Entity Type:Individual
Prefix:
First Name:DARIUSZ
Middle Name:
Last Name:KOSTRZEWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:360 KINGSTOWN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NARRAGANSETT
Practice Address - State:RI
Practice Address - Zip Code:02882-3239
Practice Address - Country:US
Practice Address - Phone:401-783-6940
Practice Address - Fax:401-792-3676
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9003474Medicaid
RI27604OtherBLUE CROSS/BLUE SHIELD
RI0890034741Medicare PIN
RI27604OtherBLUE CROSS/BLUE SHIELD
I08083Medicare UPIN