Provider Demographics
NPI:1720006828
Name:KOSTECKI, CARISSA J (MD)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:J
Last Name:KOSTECKI
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 1:820 PRUDENTIAL DR STE 713
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8209
Mailing Address - Country:US
Mailing Address - Phone:904-396-5682
Mailing Address - Fax:904-346-0864
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:904-346-0864
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME852332080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265150500Medicaid
FL29056OtherBCBS
GA000960352AMedicaid
FL29056AMedicare PIN
FLH64979Medicare UPIN
GA000960352AMedicaid