MEDICARE: DR. DIANA LOWRY KOSLOWSKE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901003577	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	203516664	OTHER	MI	TAX ID
2	900D115230	OTHER	MI	BCBS OF MICHIGAN

General Provider Information

NPI Number	:	1053306274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANA LOWRY KOSLOWSKE O.D.

Provider Business Mailing Address
First Line	:	511 WILSON AVE NW
Second Line	:	SUITE G
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-7986
Country	:	US
Telephone Number	:	616-301-8663
Fax Number	:	616-301-2987

Provider Business Practice Location Address
First Line	:	511 WILSON AVE NW
Second Line	:	SUITE G
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-7986
Country	:	US
Telephone Number	:	616-301-8663
Fax Number	:	616-301-2987

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	05/20/2008

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Directions to “ DR. DIANA LOWRY KOSLOWSKE O.D.” Practice Location

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