Provider Demographics
NPI:1639317217
Name:KOSTIV, ALEX (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:KOSTIV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OLEKSANDR
Other - Middle Name:
Other - Last Name:KOSTIV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2056
Mailing Address - Street 2:SUITE 190
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-2056
Mailing Address - Country:US
Mailing Address - Phone:847-858-7367
Mailing Address - Fax:847-825-0803
Practice Address - Street 1:565 LAKEVIEW PKWY
Practice Address - Street 2:SUITE 190
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1857
Practice Address - Country:US
Practice Address - Phone:847-549-3171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.127007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine