Provider Demographics
NPI:1831192079
Name:KOSIBOROD, ROMAN N (DO)
Entity type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:N
Last Name:KOSIBOROD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 VANCE AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-3016
Mailing Address - Country:US
Mailing Address - Phone:201-982-4706
Mailing Address - Fax:973-246-7120
Practice Address - Street 1:39-40 BROADWAY STE 1
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-509-8998
Practice Address - Fax:973-246-7120
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07566200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI00784Medicare UPIN
NJ076456Medicare ID - Type Unspecified