MEDICARE: DR. JOSEPH MAX KOSTECKI O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	LD2820000	MN

General Provider Information

NPI Number	:	1366434672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH MAX KOSTECKI O.D.

Provider Business Mailing Address
First Line	:	4848 COUNTY ROAD 101
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-2635
Country	:	US
Telephone Number	:	952-401-9202
Fax Number	:	952-401-9379

Provider Business Practice Location Address
First Line	:	4848 COUNTY ROAD 101
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-2635
Country	:	US
Telephone Number	:	952-401-9202
Fax Number	:	952-401-9379

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	02/11/2015

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