Provider Demographics
NPI:1841289774
Name:KOSCIUSZKO, MARK EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:KOSCIUSZKO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W CARLETON RD
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-1202
Mailing Address - Country:US
Mailing Address - Phone:517-439-2020
Mailing Address - Fax:517-437-5577
Practice Address - Street 1:50 W CARLETON RD
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-1202
Practice Address - Country:US
Practice Address - Phone:517-439-2020
Practice Address - Fax:517-437-5577
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002884152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI37252313OtherVSP
MI4696989Medicaid
MI2230027OtherIBA PHP
MI4414910001OtherDMERC
MI900A210280OtherBCBSM
MI4414910001OtherDMERC
MIU29910Medicare UPIN