Provider Demographics
NPI:1043979412
Name:COSPY, BRELAND JUWAN
Entity Type:Individual
Prefix:
First Name:BRELAND
Middle Name:JUWAN
Last Name:COSPY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 STUBBS DR
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-3160
Mailing Address - Country:US
Mailing Address - Phone:937-815-4673
Mailing Address - Fax:
Practice Address - Street 1:317 STUBBS DR
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-3160
Practice Address - Country:US
Practice Address - Phone:937-815-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUH298850172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty