Healthcare Provider Details

I. General information

NPI: 1477549764
Provider Name (Legal Business Name): JOSEPHINE MANGONI KOSUNICK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 W ROYALTON RD
BROADVIEW HEIGHTS OH
44147-2407
US

IV. Provider business mailing address

1261 W ROYALTON RD
BROADVIEW HEIGHTS OH
44147-2407
US

V. Phone/Fax

Practice location:
  • Phone: 440-526-7070
  • Fax:
Mailing address:
  • Phone: 440-526-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5326
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: