Provider Demographics
NPI:1578755757
Name:KOSTELECKY, EVE L (OD)
Entity type:Individual
Prefix:DR
First Name:EVE
Middle Name:L
Last Name:KOSTELECKY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3144
Mailing Address - Country:US
Mailing Address - Phone:701-751-2330
Mailing Address - Fax:701-751-2338
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3144
Practice Address - Country:US
Practice Address - Phone:701-751-2330
Practice Address - Fax:701-751-2338
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND713212Medicare PIN