Provider Demographics
NPI:1629018627
Name:KOSLOW, PAUL M
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:KOSLOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8911 63RD DR
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3852
Mailing Address - Country:US
Mailing Address - Phone:718-639-9887
Mailing Address - Fax:718-457-5308
Practice Address - Street 1:8911 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3852
Practice Address - Country:US
Practice Address - Phone:718-639-9887
Practice Address - Fax:718-457-5308
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005473213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01945371Medicaid
NY1499548OtherGHI
NY03958Medicare ID - Type UnspecifiedGHI MEDICARE
NYU774182Medicare UPIN
NY01945371Medicaid