Provider Demographics
NPI:1548328800
Name:KOSTENKO, MICHAEL MERRITT (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MERRITT
Last Name:KOSTENKO
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:P O BOX 88
Mailing Address - Street 2:3050 C & O DAM ROAD
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832
Mailing Address - Country:US
Mailing Address - Phone:304-763-0199
Mailing Address - Fax:304-763-2137
Practice Address - Street 1:3050 C & O DAM ROAD
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832
Practice Address - Country:US
Practice Address - Phone:304-763-0199
Practice Address - Fax:304-763-2137
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV1078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVE84476Medicare UPIN