Provider Demographics
NPI:1386057776
Name:KOSTRUB, JUSTINE (MD)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:KOSTRUB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 BLACKBURN RD., 1ST FLOOR
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143
Mailing Address - Country:US
Mailing Address - Phone:412-741-0985
Mailing Address - Fax:412-749-6785
Practice Address - Street 1:720 BLACKBURN RD FL 1
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-1459
Practice Address - Country:US
Practice Address - Phone:412-741-0985
Practice Address - Fax:412-749-6785
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT-207188390200000X
PAMD461424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103147653Medicaid