Healthcare Provider Details

I. General information

NPI: 1083110530
Provider Name (Legal Business Name): PIOTR KOSTYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR ST - TMP3
NEW HAVEN CT
06510-3206
US

IV. Provider business mailing address

333 CEDAR ST - TMP3
NEW HAVEN CT
06510-3206
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4242
  • Fax:
Mailing address:
  • Phone: 203-688-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number75699
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: