Provider Demographics
NPI:1831181411
Name:KOSTESICH, JOSEPH (OD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:KOSTESICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51950 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-4453
Mailing Address - Country:US
Mailing Address - Phone:586-254-9030
Mailing Address - Fax:
Practice Address - Street 1:51950 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-4453
Practice Address - Country:US
Practice Address - Phone:586-254-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E06638OtherMEDICARE PTAN
MI0191690001Medicare NSC
MIT33225Medicare UPIN