Provider Demographics
NPI:1225630965
Name:DJAGLI, KOSSIVI ROGER
Entity Type:Individual
Prefix:
First Name:KOSSIVI
Middle Name:ROGER
Last Name:DJAGLI
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:PO BOX 20141
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-0141
Mailing Address - Country:US
Mailing Address - Phone:614-592-9049
Mailing Address - Fax:614-364-7469
Practice Address - Street 1:545 METRO PL S STE 100
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5353
Practice Address - Country:US
Practice Address - Phone:614-592-9049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide