Provider Demographics
NPI:1760599849
Name:KOSTINER, ANTHONY IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:IVAN
Last Name:KOSTINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8535 SW BOHMANN PKWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-7225
Mailing Address - Country:US
Mailing Address - Phone:503-245-5312
Mailing Address - Fax:503-246-8951
Practice Address - Street 1:3500 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-904-8190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD087952085R0202X
WAMD000112042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology