Provider Demographics
NPI:1952323404
Name:COSGROVE, JEFFERY CLINTON (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:CLINTON
Last Name:COSGROVE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-6926
Mailing Address - Country:US
Mailing Address - Phone:269-323-4605
Mailing Address - Fax:
Practice Address - Street 1:1905 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-6926
Practice Address - Country:US
Practice Address - Phone:269-323-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003809152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management