Provider Demographics
NPI:1790884666
Name:KOSS, LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:KOSS
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 1:7277 SNOWBALL RUN
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3212
Mailing Address - Country:US
Mailing Address - Phone:315-656-2698
Mailing Address - Fax:206-426-2313
Practice Address - Street 1:3045 EAST AVE
Practice Address - Street 2:LIFETIME HEALTH CENTER BUILDING
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-9502
Practice Address - Country:US
Practice Address - Phone:315-668-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355266Medicaid
NY00355266Medicaid
NYCC7918Medicare ID - Type Unspecified