Healthcare Provider Details

I. General information

NPI: 1073599775
Provider Name (Legal Business Name): JASMINKA KOSTIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3114 W IRVING PARK RD
CHICAGO IL
60618-3406
US

IV. Provider business mailing address

3114 W IRVING PARK RD
CHICAGO IL
60618-3406
US

V. Phone/Fax

Practice location:
  • Phone: 773-588-6680
  • Fax: 773-588-6451
Mailing address:
  • Phone: 773-588-6680
  • Fax: 773-588-6451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036104292
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036104292
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: