Provider Demographics
NPI:1033104104
Name:KOCOLOSKI, PHILIP W (DO)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:W
Last Name:KOCOLOSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 BETHESDA DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1880
Mailing Address - Country:US
Mailing Address - Phone:740-454-4788
Mailing Address - Fax:
Practice Address - Street 1:2945 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1762
Practice Address - Country:US
Practice Address - Phone:740-454-4712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005265207L00000X
OH34-005265208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0841665Medicaid
OH0696158Medicare PIN
OH0841665Medicaid