Provider Demographics
NPI:1700039161
Name:ALEXANDRA KOSTICK MD PA
Entity Type:Organization
Organization Name:ALEXANDRA KOSTICK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:MARION PAMELA
Authorized Official - Last Name:KOSTICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-446-9590
Mailing Address - Street 1:3 PINE CONE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8685
Mailing Address - Country:US
Mailing Address - Phone:386-446-9590
Mailing Address - Fax:
Practice Address - Street 1:3 PINE CONE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8685
Practice Address - Country:US
Practice Address - Phone:386-446-9590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63389207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG08633Medicare UPIN