Provider Demographics
NPI:1689680696
Name:KOSHAK, MICHAEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:KOSHAK
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:11631 VICTORY BLVD
Mailing Address - Street 2:#101
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3572
Mailing Address - Country:US
Mailing Address - Phone:818-764-8838
Mailing Address - Fax:818-432-2238
Practice Address - Street 1:11631 VICTORY BLVD
Practice Address - Street 2:101
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3572
Practice Address - Country:US
Practice Address - Phone:818-764-8838
Practice Address - Fax:818-432-2238
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA36588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine