Provider Demographics
NPI:1467241067
Name:KOSTIN, YURY
Entity type:Individual
Prefix:
First Name:YURY
Middle Name:
Last Name:KOSTIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24681 S ELDA CT APT 81C
Mailing Address - Street 2:
Mailing Address - City:HARRISON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-2376
Mailing Address - Country:US
Mailing Address - Phone:586-344-9190
Mailing Address - Fax:
Practice Address - Street 1:24681 S ELDA CT APT 81C
Practice Address - Street 2:
Practice Address - City:HARRISON TWP
Practice Address - State:MI
Practice Address - Zip Code:48045-2376
Practice Address - Country:US
Practice Address - Phone:586-344-9190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI800529342171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor