Provider Demographics
NPI:1588854848
Name:KOCIASVILI, KONSTANTINS (MD)
Entity Type:Individual
Prefix:
First Name:KONSTANTINS
Middle Name:
Last Name:KOCIASVILI
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 1:333 W DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3545
Mailing Address - Country:US
Mailing Address - Phone:847-243-0355
Mailing Address - Fax:847-243-0356
Practice Address - Street 1:3633 W LAKE AVE STE 307
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5803
Practice Address - Country:US
Practice Address - Phone:847-626-8722
Practice Address - Fax:847-316-9502
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036135325207QA0505X
WAMD60354382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125052607Other125052607
IL036135325Medicaid