Provider Demographics
NPI:1932207370
Name:COSACHOV, JOHN D (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:COSACHOV
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 1:37 W GARDEN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-2657
Mailing Address - Country:US
Mailing Address - Phone:315-252-9562
Mailing Address - Fax:315-255-3872
Practice Address - Street 1:37 W GARDEN ST STE 206
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-2657
Practice Address - Country:US
Practice Address - Phone:315-252-9562
Practice Address - Fax:315-255-3872
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193747207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY035642OtherMVP
NYP010193747OtherBLUE CHOICE
NY01572178Medicaid
NY035642OtherMVP