Provider Demographics
NPI:1649638073
Name:KOSTIN, VLADISLAV (DC)
Entity type:Individual
Prefix:
First Name:VLADISLAV
Middle Name:
Last Name:KOSTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 NE 181ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-6615
Mailing Address - Country:US
Mailing Address - Phone:503-512-7076
Mailing Address - Fax:503-512-7092
Practice Address - Street 1:205 NE 181ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6615
Practice Address - Country:US
Practice Address - Phone:503-512-7076
Practice Address - Fax:503-512-7092
Is Sole Proprietor?:No
Enumeration Date:2016-01-30
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5706111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor