Provider Demographics
NPI:1376529420
Name:KOSTACOS, CONNIE
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:KOSTACOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1559
Mailing Address - Country:US
Mailing Address - Phone:212-304-7250
Mailing Address - Fax:
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-304-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2002961208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01694655Medicaid
NY537121Medicare ID - Type Unspecified
NY01694655Medicaid