Provider Demographics
NPI:1982633616
Name:ELIZABETH KOSTREY, MD, INC
Entity Type:Organization
Organization Name:ELIZABETH KOSTREY, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-957-2248
Mailing Address - Street 1:2258 FOOTHILL BLVD
Mailing Address - Street 2:SUITE300
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1457
Mailing Address - Country:US
Mailing Address - Phone:818-957-2248
Mailing Address - Fax:818-249-1425
Practice Address - Street 1:2258 FOOTHILL BLVD
Practice Address - Street 2:SUITE300
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-1457
Practice Address - Country:US
Practice Address - Phone:818-957-2248
Practice Address - Fax:818-249-1425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76521261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851347769OtherNPI INDIVIDUAL
CAH91831Medicare UPIN
CA1851347769OtherNPI INDIVIDUAL