Provider Demographics
NPI:1932884368
Name:KOSTYLEVA, EKATERINA
Entity Type:Individual
Prefix:MISS
First Name:EKATERINA
Middle Name:
Last Name:KOSTYLEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 NE 12TH AVE APT 10B
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4550
Mailing Address - Country:US
Mailing Address - Phone:786-438-6737
Mailing Address - Fax:
Practice Address - Street 1:1250 E HALLANDALE BEACH BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4644
Practice Address - Country:US
Practice Address - Phone:786-438-6737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026614207NS0135X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology