Healthcare Provider Details

I. General information

NPI: 1790884666
Provider Name (Legal Business Name): LAWRENCE KOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 EAST AVE LIFETIME HEALTH CENTER BUILDING
CENTRAL SQUARE NY
13036-9502
US

IV. Provider business mailing address

7277 SNOWBALL RUN
EAST SYRACUSE NY
13057-3212
US

V. Phone/Fax

Practice location:
  • Phone: 315-668-1202
  • Fax:
Mailing address:
  • Phone: 315-656-2698
  • Fax: 206-426-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number208062
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: