Provider Demographics
NPI:1336139187
Name:KOSTICK, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:KOSTICK
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 1:11945 SAN JOSE BLVD 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:UNIT 534
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-642-2222
Practice Address - Fax:904-683-3934
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68360207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000685836AMedicaid
FL377942400Medicaid
FL180022583OtherRAILROAD MEDICARE
FL27478OtherBLUE CROSS BLUE SHIELD
FL180022583OtherRAILROAD MEDICARE
FL27478ZMedicare ID - Type Unspecified
FL27478YMedicare PIN