Provider Demographics
NPI:1295840130
Name:KOSMICKI, DOUGLAS LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LEE
Last Name:KOSMICKI
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 1:7440 S 91ST ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-9797
Mailing Address - Country:US
Mailing Address - Phone:402-489-6555
Mailing Address - Fax:402-328-3770
Practice Address - Street 1:3515 RICHMOND CIRCLE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4965
Practice Address - Country:US
Practice Address - Phone:308-381-8636
Practice Address - Fax:308-381-8622
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE24681207RC0000X, 207RI0011X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026072500Medicaid
NE47070592302Medicaid
NE47070592305Medicaid
NE47070592313Medicaid
KS200567060AMedicaid
NE10026072400Medicaid
IA1202489Medicaid
NE10026072300Medicaid
NE47070592300Medicaid
NE47070592301Medicaid
IA0202486Medicaid
NE47070592306Medicaid
NE47070592306Medicaid
IA1202489Medicaid
KS200567060AMedicaid
NE10026072300Medicaid
NENA1080004Medicare PIN