1184799892 NPI number — CHARLES RICHARD KOSSMAN M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184799892 NPI number — CHARLES RICHARD KOSSMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSSMAN
Provider First Name:
CHARLES
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184799892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3075 HEALTH CENTER DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-2773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-637-7888
Provider Business Mailing Address Fax Number:
858-637-7887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5555 RESERVOIR DR
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-5134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-287-9910
Provider Business Practice Location Address Fax Number:
619-287-3526
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  G28857 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CN534Z . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1629046925 . This is a "MEDICAL ONCOLOGY ASSOCIATES OF SAN DIEGO NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G28857 . This is a "CA LIC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: AK7033171 . This is a "D.E.A" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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