Healthcare Provider Details

I. General information

NPI: 1396079737
Provider Name (Legal Business Name): CARLOS COSSIO MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1077 BAXTER ST SUITE K
ATHENS GA
30606-3767
US

IV. Provider business mailing address

1077 BAXTER ST SUITE K
ATHENS GA
30606-3767
US

V. Phone/Fax

Practice location:
  • Phone: 706-613-0313
  • Fax: 706-613-0229
Mailing address:
  • Phone: 706-613-0313
  • Fax: 706-613-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036127
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number036127
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036127
License Number StateGA

VIII. Authorized Official

Name: CARLOS COSSIO
Title or Position: MEDICAL DIRECTOR/PHYSICIAN
Credential: MD
Phone: 716-613-0313