Provider Demographics
NPI:1972591055
Name:KOSTUCHENKO, PAUL J (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:KOSTUCHENKO
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 1:1351-B WESTGATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3041
Mailing Address - Country:US
Mailing Address - Phone:336-768-1280
Mailing Address - Fax:336-760-8444
Practice Address - Street 1:1345 WESTGATE CENTER DR STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3041
Practice Address - Country:US
Practice Address - Phone:336-768-1280
Practice Address - Fax:336-760-8443
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400056207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ0005FMedicaid
NC89136R2Medicaid
NC2026585Medicare ID - Type UnspecifiedMEDICARE
NC89136R2Medicaid
NCI09407Medicare UPIN