Basic Information
| Provider Information | |||||||||
| NPI: | 1720006828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSTECKI | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 PRUDENTIAL DR STE 713 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043965682 | ||||||||
| FaxNumber: | 9043460864 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 PRUDENTIAL DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043965682 | ||||||||
| FaxNumber: | 9043460864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | ME85233 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 265150500 | 05 | FL | MEDICAID | 29056 | 01 | FL | BCBS | OTHER | 000960352A | 05 | GA | MEDICAID |