Provider Demographics
NPI:1184055303
Name:KOSANOVIC, RADOMIR (MD)
Entity type:Individual
Prefix:
First Name:RADOMIR
Middle Name:
Last Name:KOSANOVIC
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:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-596-3876
Mailing Address - Fax:
Practice Address - Street 1:6200 SUNSET DR STE 120
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4832
Practice Address - Country:US
Practice Address - Phone:786-596-3876
Practice Address - Fax:786-533-9989
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME152087208VP0014X, 208100000X
IN01083026A208VP0014X
KY53028208VP0014X
IL36.143746208VP0014X
WI18382208100000X
IL036143746208100000X
KY53208208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQMP000005573901Medicaid
IN300033818Medicaid
KY7100644790Medicaid