Provider Demographics
NPI:1881250363
Name:KOSUBEVSKY, BENJAMIN (DO)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:KOSUBEVSKY
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 1:15659 113TH TRL N
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478-6738
Mailing Address - Country:US
Mailing Address - Phone:732-861-4429
Mailing Address - Fax:
Practice Address - Street 1:580 VILLAGE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-1952
Practice Address - Country:US
Practice Address - Phone:561-210-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16964207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program