Provider Demographics
NPI:1417091992
Name:KMD MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:KMD MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACS FRCSC
Authorized Official - Phone:858-637-4800
Mailing Address - Street 1:501 KRISTEN CT
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7910 FROST ST
Practice Address - Street 2:SUITE 250
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2771
Practice Address - Country:US
Practice Address - Phone:858-637-4800
Practice Address - Fax:858-637-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60375204F00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE226YOtherMEDICARE PTAN (BALBOA NEPHROLOGY MEDICAL GROUP)
WA60375Medicare ID - Type Unspecified
CA867378Medicare UPIN