Provider Demographics
NPI:1881775518
Name:KOSOBUCKI, DANIEL E JR (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:E
Last Name:KOSOBUCKI
Suffix:JR
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:850 BROOKSTONE CENTRE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-9245
Mailing Address - Country:US
Mailing Address - Phone:706-507-5320
Mailing Address - Fax:706-507-4747
Practice Address - Street 1:850 BROOKSTONE CENTRE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9245
Practice Address - Country:US
Practice Address - Phone:706-507-5320
Practice Address - Fax:706-507-4741
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA045857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00795803DMedicaid
GA00795803DMedicaid
GAG63006Medicare UPIN