Provider Demographics
NPI:1558348136
Name:KOSOVA, MARLENE R (DPM)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:R
Last Name:KOSOVA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 BROM DRIVE STE 201
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6792
Mailing Address - Country:US
Mailing Address - Phone:630-355-3668
Mailing Address - Fax:630-355-3016
Practice Address - Street 1:640 S WASHINGTON ST STE 240
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6792
Practice Address - Country:US
Practice Address - Phone:630-355-3668
Practice Address - Fax:630-355-3016
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004406213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004406Medicaid
480032631OtherRR MEDICARE
IL2230194OtherBC
480032631OtherRR MEDICARE
L85804Medicare ID - Type Unspecified