Provider Demographics
NPI:1750957361
Name:COSBY, CHARLES RYAN (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RYAN
Last Name:COSBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:RYAN
Other - Last Name:COSBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:58 BIG A RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6017
Practice Address - Country:US
Practice Address - Phone:706-886-3148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA99941207Q00000X
GA12849207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12849Medicaid