Provider Demographics
NPI:1316357858
Name:KOSS, ANASTASIA (DPM)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:KOSS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:ANASTASIA
Other - Middle Name:
Other - Last Name:SAMOUILOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:6474 CENTERVILLE BUSINESS PKWY
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2633
Mailing Address - Country:US
Mailing Address - Phone:937-435-7477
Mailing Address - Fax:937-435-6644
Practice Address - Street 1:6474 CENTERVILLE BUSINESS PKWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-2633
Practice Address - Country:US
Practice Address - Phone:937-435-7477
Practice Address - Fax:937-435-6644
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003807213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0223320Medicaid