=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902158934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT KOSTOROSKI D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2012
-----------------------------------------------------
Last Update Date | 10/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 ALTON RD
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33140-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-674-2121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18495 S DIXIE HWY # 125
-----------------------------------------------------
City | CUTLER BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-6817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-623-6310
-----------------------------------------------------
Fax | 786-272-0557
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | OS11923
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------