Provider Demographics
NPI:1447316799
Name:KOSTUR, GREGORY DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DANIEL
Last Name:KOSTUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-2408
Practice Address - Street 1:500 S 11TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4878
Practice Address - Country:US
Practice Address - Phone:208-232-3355
Practice Address - Fax:855-230-7350
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3122208000000X
IDM-14706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics