Provider Demographics
NPI:1801805031
Name:KOSTREY, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:KOSTREY
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 1:217 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3742
Mailing Address - Country:US
Mailing Address - Phone:815-758-8671
Mailing Address - Fax:
Practice Address - Street 1:217 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3742
Practice Address - Country:US
Practice Address - Phone:815-758-8671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL008459OtherHEALTH ALLIANCE
IL008459OtherHEALTH ALLIANCE
IL008459OtherHEALTH ALLIANCE
ILAK4138512OtherDEA