Provider Demographics
NPI:1326102542
Name:KOSTELECKY, MICHAEL G (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:KOSTELECKY
Suffix:
Gender:M
Credentials:OD
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Other - Credentials:
Mailing Address - Street 1:2331 TYLER PARKWAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503
Mailing Address - Country:US
Mailing Address - Phone:701-258-4384
Mailing Address - Fax:701-258-4394
Practice Address - Street 1:2331 TYLER PARKWAY
Practice Address - Street 2:SUITE 2
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503
Practice Address - Country:US
Practice Address - Phone:701-258-4384
Practice Address - Fax:701-258-4394
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-02-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ND463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND712505Medicare PIN