Provider Demographics
NPI:1568853158
Name:KOSTKO MEDICAL PLLC
Entity Type:Organization
Organization Name:KOSTKO MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEMYON
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-459-8900
Mailing Address - Street 1:9876 QUEENS BLVD
Mailing Address - Street 2:STE1JK
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4398
Mailing Address - Country:US
Mailing Address - Phone:718-459-8900
Mailing Address - Fax:718-459-8903
Practice Address - Street 1:9876 QUEENS BLVD
Practice Address - Street 2:STE1JK
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4398
Practice Address - Country:US
Practice Address - Phone:718-459-8900
Practice Address - Fax:718-459-8903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-18
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02621089Medicaid