Healthcare Provider Details

I. General information

NPI: 1316575889
Provider Name (Legal Business Name): STEFAN KOSTELYNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 MAIN ST
HOUSTON TX
77030-2351
US

IV. Provider business mailing address

3759 BAY LAUREL LN
VERONA WI
53593-8120
US

V. Phone/Fax

Practice location:
  • Phone: 832-824-1000
  • Fax:
Mailing address:
  • Phone: 608-556-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV1160
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberV1160
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: