Healthcare Provider Details

I. General information

NPI: 1356322416
Provider Name (Legal Business Name): KENT IAN KOSSOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HIGHWAY 61 N
VICKSBURG MS
39183-8211
US

IV. Provider business mailing address

1322 SHELTERING OAKS LN
KINGWOOD TX
77345-2187
US

V. Phone/Fax

Practice location:
  • Phone: 601-883-6300
  • Fax:
Mailing address:
  • Phone: 832-335-8245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberJ0558
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: