Provider Demographics
NPI:1740324631
Name:KOSSOW, MICHAEL KENNETH HENRY (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH HENRY
Last Name:KOSSOW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1038 ROME BEAUTY DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-3142
Mailing Address - Country:US
Mailing Address - Phone:440-724-0442
Mailing Address - Fax:216-741-6653
Practice Address - Street 1:1038 ROME BEAUTY DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-3142
Practice Address - Country:US
Practice Address - Phone:440-724-0442
Practice Address - Fax:216-741-6653
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4945152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist