Provider Demographics
NPI:1700913829
Name:KOSTURA, MICHAEL RICHARD II (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:KOSTURA
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:21612 PLANO TRABUCO RD STE C
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3488
Mailing Address - Country:US
Mailing Address - Phone:949-459-5687
Mailing Address - Fax:949-459-5690
Practice Address - Street 1:21612 PLANO TRABUCO RD STE C
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-3488
Practice Address - Country:US
Practice Address - Phone:949-459-5687
Practice Address - Fax:949-459-5690
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12316T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU98889Medicare UPIN