Healthcare Provider Details

I. General information

NPI: 1558374959
Provider Name (Legal Business Name): ELIZABETH ANN KOSKI OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ANN FRIES

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 SOMERSET BLVD
CHARLES TOWN WV
25414-5625
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 304-725-4828
  • Fax: 304-725-4829
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1037OD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: