Healthcare Provider Details

I. General information

NPI: 1497782239
Provider Name (Legal Business Name): CHRIS A KOSAKOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SONOMA AVE STE 112
SANTA ROSA CA
95405-4813
US

IV. Provider business mailing address

1111 SONOMA AVE STE 112
SANTA ROSA CA
95405-4813
US

V. Phone/Fax

Practice location:
  • Phone: 707-579-5520
  • Fax: 707-579-8820
Mailing address:
  • Phone: 707-579-5520
  • Fax: 707-579-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberG494990
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG494990
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: