Provider Demographics
NPI:1033118781
Name:COSSIO, CARLOS MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MIGUEL
Last Name:COSSIO
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 1:1077 BAXTER ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3767
Mailing Address - Country:US
Mailing Address - Phone:706-613-0313
Mailing Address - Fax:706-613-0229
Practice Address - Street 1:1077 BAXTER ST
Practice Address - Street 2:SUITE K
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3767
Practice Address - Country:US
Practice Address - Phone:706-613-0313
Practice Address - Fax:706-613-0229
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2009-08-17
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
GA036127174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00544123DMedicaid
F67095Medicare UPIN
GA00544123DMedicaid