MEDICARE: DR. JOSEPH KOSTESICH O.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	152W00000X	Optometrist	4901002753	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0E06638	OTHER	MI	MEDICARE PTAN

General Provider Information

NPI Number	:	1831181411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH KOSTESICH O.D.

Provider Business Mailing Address
First Line	:	51950 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-4453
Country	:	US
Telephone Number	:	586-254-9030
Fax Number	:

Provider Business Practice Location Address
First Line	:	51950 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-4453
Country	:	US
Telephone Number	:	586-254-9030
Fax Number	:

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	02/17/2015

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