Provider Demographics
NPI:1023472107
Name:KOSTKA, RYAN (DO)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:KOSTKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7214 LA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-4226
Mailing Address - Country:US
Mailing Address - Phone:720-201-4084
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-3000
Practice Address - Fax:817-927-3958
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT0543208600000X, 2086S0127X, 2086S0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program