Provider Demographics
NPI:1811924574
Name:COSENZA, MICHAEL RUDOLPH (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RUDOLPH
Last Name:COSENZA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 HOSPITAL DR STE B
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482
Mailing Address - Country:US
Mailing Address - Phone:707-463-3668
Mailing Address - Fax:707-463-3664
Practice Address - Street 1:238 HOSPITAL DR STE B
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482
Practice Address - Country:US
Practice Address - Phone:707-463-3668
Practice Address - Fax:707-463-3664
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4380213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU88390Medicare UPIN
CA1811924574Medicare NSC