Provider Demographics
NPI:1982635397
Name:KOSTIC, KATHRYN J (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:J
Last Name:KOSTIC
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 1:3003 W GOOD HOPE ROAD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1777 W GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074
Practice Address - Country:US
Practice Address - Phone:262-284-3456
Practice Address - Fax:262-284-4543
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39904207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00671026OtherRR MEDICARE
WI32456300Medicaid
WI01994-0118Medicare PIN
WIP00671026OtherRR MEDICARE
G55853Medicare UPIN