Provider Demographics
NPI:1710972849
Name:KOSSOW, RONALD J (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:KOSSOW
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:PO BOX 713100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-3100
Mailing Address - Country:US
Mailing Address - Phone:801-930-3842
Mailing Address - Fax:866-588-2820
Practice Address - Street 1:3700 SOUTHERN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1226
Practice Address - Country:US
Practice Address - Phone:937-281-3810
Practice Address - Fax:937-281-3812
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070743L2085R0001X
OH351305692085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011126Medicaid
PA1018952570001Medicaid
PA114912PDBMedicare PIN
WV3810011126Medicaid