Provider Demographics
NPI:1386719953
Name:KOSTERMAN, DANIEL J (OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:KOSTERMAN
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 OLD GLENN HWY 106B
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577
Mailing Address - Country:US
Mailing Address - Phone:907-696-8733
Mailing Address - Fax:907-696-8733
Practice Address - Street 1:11401 OLD GLENN HWY 106B
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577
Practice Address - Country:US
Practice Address - Phone:907-696-8733
Practice Address - Fax:907-696-8733
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK161152W00000X
AKOPTT161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD1161Medicaid
AKK160660Medicare ID - Type UnspecifiedGROUP
AK160661Medicare ID - Type UnspecifiedOPTOMETRIST
AKOD1161Medicaid