Provider Demographics
NPI:1184642951
Name:KOSTA, JOHN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:KOSTA
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 1:655 KENMOOR AVE SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8622
Mailing Address - Country:US
Mailing Address - Phone:616-575-1212
Mailing Address - Fax:616-575-1219
Practice Address - Street 1:655 KENMOOR AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8622
Practice Address - Country:US
Practice Address - Phone:616-575-1212
Practice Address - Fax:616-575-1219
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK046253207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D11035OtherBLUE CROSS BLUE SHIELD
MI40004194OtherRAILROAD MEDICARE
MI1822580Medicaid
MI412013Medicare ID - Type Unspecified
MIB44872Medicare UPIN
MIP58750004Medicare PIN