Healthcare Provider Details

I. General information

NPI: 1548328800
Provider Name (Legal Business Name): MICHAEL MERRITT KOSTENKO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 C & O DAM ROAD
DANIELS WV
25832
US

IV. Provider business mailing address

P O BOX 88 3050 C & O DAM ROAD
DANIELS WV
25832
US

V. Phone/Fax

Practice location:
  • Phone: 304-763-0199
  • Fax: 304-763-2137
Mailing address:
  • Phone: 304-763-0199
  • Fax: 304-763-2137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1078
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: