Healthcare Provider Details

I. General information

NPI: 1568853158
Provider Name (Legal Business Name): KOSTKO MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9932 66TH RD STE LP
REGO PARK NY
11374-4401
US

IV. Provider business mailing address

9932 66TH RD STE LP
REGO PARK NY
11374-4401
US

V. Phone/Fax

Practice location:
  • Phone: 718-459-8900
  • Fax: 718-459-8903
Mailing address:
  • Phone: 718-459-8900
  • Fax: 718-459-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SEMYON KOSTKO
Title or Position: PRESIDENT
Credential: MD
Phone: 718-459-8900