Healthcare Provider Details

I. General information

NPI: 1831992445
Provider Name (Legal Business Name): NIKITA KOSTRUBSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2025
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4741
  • Fax: 401-444-4445
Mailing address:
  • Phone: 401-444-4741
  • Fax: 401-444-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLP06901
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: