Provider Demographics
NPI:1366434672
Name:KOSTECKI, JOSEPH MAX (OD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MAX
Last Name:KOSTECKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 COUNTY ROAD 101
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2635
Mailing Address - Country:US
Mailing Address - Phone:952-401-9202
Mailing Address - Fax:952-401-9379
Practice Address - Street 1:4848 COUNTY ROAD 101
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-2635
Practice Address - Country:US
Practice Address - Phone:952-401-9202
Practice Address - Fax:952-401-9379
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD2820000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U88355Medicare UPIN
MN410002006Medicare ID - Type Unspecified