Provider Demographics
NPI:1790766491
Name:COSGROVE, DANIEL JEREMY (MD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JEREMY
Last Name:COSGROVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:STE 800
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:878-906-0635
Mailing Address - Fax:818-906-7303
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:STE 800
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:878-906-0635
Practice Address - Fax:818-906-7303
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAS64348208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA222046862OtherBLUE SHIELD
CA00A643480Medicaid
CAP00647439OtherRAILROAD MEDICARE PTAN
H64140Medicare UPIN
CA222046862OtherBLUE SHIELD