Provider Demographics
NPI:1942469028
Name:JEFFREY C KOSSOL, O.D., INC
Entity Type:Organization
Organization Name:JEFFREY C KOSSOL, O.D., INC
Other - Org Name:PALO CEDRO OPTOMETRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOSSOL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-547-2020
Mailing Address - Street 1:9372 DESCHUTES RD
Mailing Address - Street 2:
Mailing Address - City:PALO CEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:96073-9763
Mailing Address - Country:US
Mailing Address - Phone:530-547-2020
Mailing Address - Fax:530-547-2101
Practice Address - Street 1:9372 DESCHUTES RD
Practice Address - Street 2:
Practice Address - City:PALO CEDRO
Practice Address - State:CA
Practice Address - Zip Code:96073-9763
Practice Address - Country:US
Practice Address - Phone:530-547-2020
Practice Address - Fax:530-547-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7249 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA410045967Medicare PIN
CAT10500Medicare UPIN
CAAZ924AMedicare PIN
CA0227540002Medicare NSC