Healthcare Provider Details

I. General information

NPI: 1891794509
Provider Name (Legal Business Name): EDWARD HENRY KOSNOSKI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10002 SE 240TH ST
KENT WA
98031-4839
US

IV. Provider business mailing address

PO BOX 6609
KENT WA
98064-6609
US

V. Phone/Fax

Practice location:
  • Phone: 253-852-2020
  • Fax: 253-854-2020
Mailing address:
  • Phone: 253-852-2020
  • Fax: 253-854-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0879
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: