Healthcare Provider Details

I. General information

NPI: 1730875733
Provider Name (Legal Business Name): ARIANNA L KOSAKOWSKI OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 06/25/2023
Certification Date: 06/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 MARKET DR
ATHOL MA
01331-9829
US

IV. Provider business mailing address

184 MARKET DR
ATHOL MA
01331-9829
US

V. Phone/Fax

Practice location:
  • Phone: 978-939-3128
  • Fax: 978-650-2090
Mailing address:
  • Phone: 978-939-3128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5612
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: