Provider Demographics
NPI:1457354227
Name:KOSUB, LAURA K (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:K
Last Name:KOSUB
Suffix:
Gender:F
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 1367
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482
Mailing Address - Country:US
Mailing Address - Phone:903-885-2961
Mailing Address - Fax:903-885-5309
Practice Address - Street 1:107 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2138
Practice Address - Country:US
Practice Address - Phone:903-885-2961
Practice Address - Fax:903-885-5309
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039157503Medicaid
F77529Medicare UPIN
TX039157503Medicaid