Provider Demographics
NPI:1649266248
Name:KOSSOL, WILLIAM ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:KOSSOL
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 1:12100 KENNEDY LN
Mailing Address - Street 2:#206
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6760
Mailing Address - Country:US
Mailing Address - Phone:540-785-3937
Mailing Address - Fax:540-785-5498
Practice Address - Street 1:12100 KENNEDY LN
Practice Address - Street 2:#206
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6760
Practice Address - Country:US
Practice Address - Phone:540-785-3937
Practice Address - Fax:540-785-5498
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2009-12-18
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
VA0601001281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA17033OtherAVESIS
VA6683OtherDAVIS
VA902137OtherBLOCK
VAC09338OtherMEDICARE GROUP
VA452927OtherANTHEM BC/BS
VA09235591Medicaid
VA4091903OtherAETNA
VA2150133OtherFIRST HEALTH
VA32467OtherMAMSI
VA2150133OtherFIRST HEALTH
VAC09338OtherMEDICARE GROUP