Healthcare Provider Details

I. General information

NPI: 1417091992
Provider Name (Legal Business Name): KMD MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FROST ST SUITE 250
SAN DIEGO CA
92123-2771
US

IV. Provider business mailing address

501 KRISTEN CT
ENCINITAS CA
92024-2700
US

V. Phone/Fax

Practice location:
  • Phone: 858-637-4800
  • Fax: 858-637-4801
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberA60375
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA60375
License Number StateCA

VIII. Authorized Official

Name: DR. DANIEL KOSOY
Title or Position: PRESIDENT
Credential: MD FACS FRCSC
Phone: 858-637-4800