Provider Demographics
NPI:1568459659
Name:KOSANKE, EDWARD PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PAUL
Last Name:KOSANKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-2220
Mailing Address - Country:US
Mailing Address - Phone:231-627-5666
Mailing Address - Fax:231-627-5487
Practice Address - Street 1:730 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2220
Practice Address - Country:US
Practice Address - Phone:231-627-5666
Practice Address - Fax:231-627-5487
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900A66502OtherBCBS
MI94-5103234Medicaid
MIT32684Medicare UPIN
MI900A66502OtherBCBS
MI94-5103234Medicaid