Provider Demographics
NPI:1720014962
Name:KOSTMAN, JAY R (MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:R
Last Name:KOSTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1233 LOCUST ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5400
Mailing Address - Country:US
Mailing Address - Phone:215-985-4448
Mailing Address - Fax:215-985-1145
Practice Address - Street 1:1207 CHESTNUT ST FL 3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4131
Practice Address - Country:US
Practice Address - Phone:267-725-0252
Practice Address - Fax:215-732-1046
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD035184E207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA761315OtherMEDICARE
PA001087179Medicaid
PA0010871790003Medicaid