Provider Demographics
NPI:1710070933
Name:KOSTAKOS, KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KOSTAKOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1603
Mailing Address - Country:US
Mailing Address - Phone:718-601-8205
Mailing Address - Fax:718-601-8693
Practice Address - Street 1:MMG - RIVERDALE
Practice Address - Street 2:3510 JOHNSON AVENUE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463
Practice Address - Country:US
Practice Address - Phone:718-601-8205
Practice Address - Fax:718-601-8693
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine