Healthcare Provider Details

I. General information

NPI: 1457320061
Provider Name (Legal Business Name): WILLIAM A KOSTUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MASSACHUSETTS AVE
TROY NY
12180-1628
US

IV. Provider business mailing address

315 2ND AVE
TROY NY
12182-3237
US

V. Phone/Fax

Practice location:
  • Phone: 518-272-7614
  • Fax:
Mailing address:
  • Phone: 518-235-6181
  • Fax: 518-237-2465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number162554
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number162554
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: