MEDICARE: CHRISTINE SUZANNE KOSELAK

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	174400000X	Specialist	30000094L	CA

General Provider Information

NPI Number	:	1669998324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE SUZANNE KOSELAK

Provider Business Mailing Address
First Line	:	14567 BIG BASIN WAY STE D2
Second Line	:
City	:	SARATOGA
State	:	CA
Zip	:	95070-6039
Country	:	US
Telephone Number	:	650-346-4111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1936 CAMDEN AVE STE 9
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2845
Country	:	US
Telephone Number	:	650-346-4111
Fax Number	:

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

Provider Enumeration Date	:	08/15/2017
Last Update Date	:	06/14/2021

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