Healthcare Provider Details

I. General information

NPI: 1295712891
Provider Name (Legal Business Name): ERIC MYLES KOSOFSKY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 ASYLUM AVE STE 111
HARTFORD CT
06105-2416
US

IV. Provider business mailing address

999 ASYLUM AVE STE 111
HARTFORD CT
06105-2416
US

V. Phone/Fax

Practice location:
  • Phone: 860-523-8026
  • Fax: 860-523-7622
Mailing address:
  • Phone: 860-523-8026
  • Fax: 860-523-7622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000468
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number000468
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: