Provider Demographics
NPI:1609857309
Name:COSGROVE, MALCOLM DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:DAVID
Last Name:COSGROVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:STE 1000
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2147
Mailing Address - Country:US
Mailing Address - Phone:818-906-0635
Mailing Address - Fax:818-906-7303
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:STE 1000
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2147
Practice Address - Country:US
Practice Address - Phone:818-906-0635
Practice Address - Fax:818-906-7303
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25183208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00647436OtherRAILROAD MEDICARE PTAN
CA00A251830Medicaid
CAZ22046856ZOtherBLUE SHIELD
A24317Medicare UPIN
CA340006193Medicare ID - Type UnspecifiedRR
CA00A251830Medicaid