MEDICARE: DR. GEORGE KOSTOHRYZ II M.D.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821062357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE KOSTOHRYZ II M.D.

Provider Business Mailing Address
First Line	:	4625 BOAT CLUB RD
Second Line	:	SUITE 257
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7022
Country	:	US
Telephone Number	:	817-346-6464
Fax Number	:	817-238-2358

Provider Business Practice Location Address
First Line	:	4625 BOAT CLUB RD
Second Line	:	SUITE 257
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7022
Country	:	US
Telephone Number	:	817-346-6464
Fax Number	:	817-238-0054

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	12/01/2010

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