Provider Demographics
NPI:1578668992
Name:KOSTROMIN, RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
Last Name:KOSTROMIN
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:PO BOX 8147
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-8147
Mailing Address - Country:US
Mailing Address - Phone:706-320-2773
Mailing Address - Fax:706-596-4226
Practice Address - Street 1:2122 MANCHESTER EXPY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6878
Practice Address - Country:US
Practice Address - Phone:706-320-2773
Practice Address - Fax:706-596-4226
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA51827207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003145993Medicaid
AL159846Medicaid
GA202I114097Medicare PIN