Basic Information
| Provider Information | |||||||||
| NPI: | 1336139187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSTICK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043991717 | ||||||||
| Practice Location | |||||||||
| Address1: | 11512 LAKE MEAD AVE | ||||||||
| Address2: | UNIT 534 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322569680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046422222 | ||||||||
| FaxNumber: | 9046833934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 12/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME68360 | FL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 000685836A | 05 | GA | MEDICAID | 377942400 | 05 | FL | MEDICAID | 180022583 | 01 | FL | RAILROAD MEDICARE | OTHER | 27478 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |