Provider Demographics
NPI:1578556924
Name:COSLETT, DOUGLAS S (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:S
Last Name:COSLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18401 VON KARMAN AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-8531
Mailing Address - Country:US
Mailing Address - Phone:714-277-3047
Mailing Address - Fax:
Practice Address - Street 1:2455 BACK MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SCOTRUN
Practice Address - State:PA
Practice Address - Zip Code:18355-7758
Practice Address - Country:US
Practice Address - Phone:579-243-8957
Practice Address - Fax:570-243-8890
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045458L2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014098620009Medicaid
PAF57984Medicare UPIN
PA0014098620009Medicaid