Provider Demographics
NPI:1881748168
Name:KOSZTACZKY, BELA ALEX (MD)
Entity type:Individual
Prefix:
First Name:BELA
Middle Name:ALEX
Last Name:KOSZTACZKY
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 1:104 FIESTA DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4964
Mailing Address - Country:US
Mailing Address - Phone:423-470-1615
Mailing Address - Fax:
Practice Address - Street 1:350 7TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5754
Practice Address - Country:US
Practice Address - Phone:239-436-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80777207R00000X
TNMD0000027776207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3800776Medicare ID - Type Unspecified
TN103I118529Medicare PIN