Basic Information
| Provider Information | |||||||||
| NPI: | 1023472107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOSTKA | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7214 LA VISTA DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752144226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202014084 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177023000 | ||||||||
| FaxNumber: | 8179273958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | T0543 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | T0543 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086S0102X | T0543 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
No ID Information.