1578556924 NPI number — DOUGLAS S COSLETT MD

Table of content: DOUGLAS S COSLETT MD (NPI 1578556924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578556924 NPI number — DOUGLAS S COSLETT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSLETT
Provider First Name:
DOUGLAS
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1578556924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18401 VON KARMAN AVE STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92612-8531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-277-3047
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2455 BACK MOUNTAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTRUN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18355-7758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
579-243-8957
Provider Business Practice Location Address Fax Number:
570-243-8890
Provider Enumeration Date:
08/31/2005

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: 2083A0300X , with the licence number:  MD045458L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0014098620009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com