Healthcare Provider Details

I. General information

NPI: 1972591055
Provider Name (Legal Business Name): PAUL J KOSTUCHENKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 WESTGATE CENTER DR STE B
WINSTON SALEM NC
27103-3041
US

IV. Provider business mailing address

1351-B WESTGATE CENTER DR
WINSTON-SALEM NC
27103-3041
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-1280
  • Fax: 336-760-8443
Mailing address:
  • Phone: 336-768-1280
  • Fax: 336-760-8444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number200400056
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: