Healthcare Provider Details

I. General information

NPI: 1447316799
Provider Name (Legal Business Name): GREGORY DANIEL KOSTUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 01/06/2024
Certification Date: 01/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 11TH AVE STE 204
POCATELLO ID
83201-4878
US

IV. Provider business mailing address

500 S 11TH AVE STE 400
POCATELLO ID
83201-4880
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-3355
  • Fax: 855-230-7350
Mailing address:
  • Phone: 208-232-7862
  • Fax: 208-232-2408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN3122
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-14706
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: