Provider Demographics
NPI:1982085593
Name:KOSTRUBALA, ANASTASIA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANASTASIA
Middle Name:
Last Name:KOSTRUBALA
Suffix:
Gender:F
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:NMRTC TWENTYNINE PALMS
Mailing Address - Street 2:1145 STURGIS RD
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277
Mailing Address - Country:US
Mailing Address - Phone:760-830-2724
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS RD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277
Practice Address - Country:US
Practice Address - Phone:760-830-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
WAMD608499382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD0000Medicare UPIN