Provider Demographics
NPI:1023433273
Name:KOSANOVICH, KENDEL
Entity type:Individual
Prefix:MR
First Name:KENDEL
Middle Name:
Last Name:KOSANOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 W LINCOLNSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1233
Mailing Address - Country:US
Mailing Address - Phone:419-245-4150
Mailing Address - Fax:
Practice Address - Street 1:3505 W LINCOLNSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1233
Practice Address - Country:US
Practice Address - Phone:419-245-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA 00348174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOTA 00348Medicaid