Healthcare Provider Details

I. General information

NPI: 1619321817
Provider Name (Legal Business Name): ANTON KOSOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 MISSOURI BLVD STE B
GRAVOIS MILLS MO
65037-5394
US

IV. Provider business mailing address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-374-5263
  • Fax: 573-374-4933
Mailing address:
  • Phone: 573-348-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019024556
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: