MEDICARE: GEORGE KOSTOHRYZ, JR., M.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	E8642	TX

General Provider Information

NPI Number	:	1346665338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGE KOSTOHRYZ, JR., M.D., P.A.

Provider Business Mailing Address
First Line	:	4625 BOAT CLUB RD STE 257
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7023
Country	:	US
Telephone Number	:	817-346-6464
Fax Number	:	817-238-2358

Provider Business Practice Location Address
First Line	:	4625 BOAT CLUB RD STE 257
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7023
Country	:	US
Telephone Number	:	817-346-6464
Fax Number	:	817-238-2358

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	GEORGE KOSTOHRYZ JR.
Credential	:	M.D.
Telephone Number	:	817-346-6464

Provider Enumeration Date	:	02/27/2014
Last Update Date	:	02/27/2014

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