Healthcare Provider Details

I. General information

NPI: 1952544876
Provider Name (Legal Business Name): THEODORE ANTHONY KOSTIUK IV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 N 120TH AVE STE 20
HOLLAND MI
49424-2196
US

IV. Provider business mailing address

370 N 120TH AVE STE 20
HOLLAND MI
49424-2196
US

V. Phone/Fax

Practice location:
  • Phone: 616-396-5855
  • Fax: 616-396-5720
Mailing address:
  • Phone: 616-396-5855
  • Fax: 616-396-5720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02004389A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number5101021584
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: