Provider Demographics
NPI:1396753646
Name:KOSTERMAN, TIMOTHY MARK (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:KOSTERMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 COOPER DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2817
Mailing Address - Country:US
Mailing Address - Phone:910-592-2250
Mailing Address - Fax:910-592-6143
Practice Address - Street 1:401 COOPER DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2817
Practice Address - Country:US
Practice Address - Phone:910-592-2250
Practice Address - Fax:910-592-6143
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001407900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890856CMedicaid
NCU02627Medicare UPIN
NC2446529Medicare ID - Type Unspecified