Provider Demographics
NPI:1881251502
Name:PROMKET, KOSMACK (OD)
Entity type:Individual
Prefix:
First Name:KOSMACK
Middle Name:
Last Name:PROMKET
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 VARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-2510
Mailing Address - Country:US
Mailing Address - Phone:978-305-7627
Mailing Address - Fax:
Practice Address - Street 1:310 DANIEL WEBSTER HWY
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-5730
Practice Address - Country:US
Practice Address - Phone:603-888-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist