Provider Demographics
NPI:1447285911
Name:KOSTADARAS, ARI (MD)
Entity type:Individual
Prefix:
First Name:ARI
Middle Name:
Last Name:KOSTADARAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4224
Mailing Address - Country:US
Mailing Address - Phone:718-721-4440
Mailing Address - Fax:718-626-4962
Practice Address - Street 1:3016 30TH DR
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-1874
Practice Address - Country:US
Practice Address - Phone:718-721-4440
Practice Address - Fax:718-907-7932
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189511207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY189511OtherLICENSE
NY189511OtherLICENSE
NY00612Medicare ID - Type Unspecified