Provider Demographics
NPI:1053306274
Name:KOSLOWSKE, DIANA LOWRY (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:LOWRY
Last Name:KOSLOWSKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:LOWRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:511 WILSON AVE NW
Mailing Address - Street 2:SUITE G
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-7986
Mailing Address - Country:US
Mailing Address - Phone:616-301-8663
Mailing Address - Fax:616-301-2987
Practice Address - Street 1:511 WILSON AVE NW
Practice Address - Street 2:SUITE G
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-7986
Practice Address - Country:US
Practice Address - Phone:616-301-8663
Practice Address - Fax:616-301-2987
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI203516664OtherTAX ID
MI900D115230OtherBCBS OF MICHIGAN
MI203516664OtherTAX ID
MI0P24930Medicare ID - Type UnspecifiedMI MEDICARE GROUP
MI5631740002Medicare NSC
MIU20850Medicare UPIN