Provider Demographics
NPI:1780779330
Name:KOSIM, SUDJONO (MD)
Entity type:Individual
Prefix:DR
First Name:SUDJONO
Middle Name:
Last Name:KOSIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HONG T JAY
Other - Middle Name:
Other - Last Name:SIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:718 N. MACOMB
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161
Mailing Address - Country:US
Mailing Address - Phone:734-240-8400
Mailing Address - Fax:
Practice Address - Street 1:718 N. MACOMB
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161
Practice Address - Country:US
Practice Address - Phone:734-240-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010402462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12915OtherCOMMUNITY CHOICE OF MI
MI3442516OtherHEALTH PLAN OF MI
MI3442490Medicaid
MI3442516OtherMOLINA HEALTHCARE
MI802982OtherCOMMUNITY CARE PLAN
MI38338429803OtherCNA HEALTH SERVICES
MI38338429803OtherCNA HEALTH SERVICES
MIA76427Medicare UPIN