Provider Demographics
NPI:1700842275
Name:KOSTELIC, JON K (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:K
Last Name:KOSTELIC
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1218 SOUTH BROADWAY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2759
Mailing Address - Country:US
Mailing Address - Phone:859-219-0542
Mailing Address - Fax:859-219-9433
Practice Address - Street 1:1218 SOUTH BROADWAY
Practice Address - Street 2:SUITE 310
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2759
Practice Address - Country:US
Practice Address - Phone:859-219-0542
Practice Address - Fax:859-219-9433
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-03-22
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Provider Licenses
StateLicense IDTaxonomies
KY326462085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64326465Medicaid
KY64326465Medicaid
KY0316530Medicare PIN
0572101Medicare PIN