Provider Demographics
NPI:1184799892
Name:KOSSMAN, CHARLES RICHARD (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
Last Name:KOSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3075 HEALTH CENTER DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2773
Mailing Address - Country:US
Mailing Address - Phone:858-637-7888
Mailing Address - Fax:858-637-7887
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:SUITE 306
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:619-287-9910
Practice Address - Fax:619-287-3526
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG28857207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACN534ZOtherMEDICARE INDIVIDUAL PTAN
CA1629046925OtherMEDICAL ONCOLOGY ASSOCIATES OF SAN DIEGO NPI
CAG28857OtherCA LIC
CAAK7033171OtherD.E.A
CACN534ZOtherMEDICARE INDIVIDUAL PTAN